Urinary incontinence: prevalence and risk factors at 16 weeks of gestation

Objective To evaluate the prevalence of urinary incontinence at 16 weeks of gestation and to identify possible maternal and obstetric risk factors.
Design Cross-sectional study and cohort study.
Setting Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark.
Population Cross-sectional study: 7795 women attending antenatal care. Cohort study: a sub-group of 1781 pregnant women with one previous delivery at our department.
Results Prevalence and maternal risk factors: the prevalence of urinary incontinence within the preceding year was 8.9% among women at 16 weeks of gestation (nulliparae, 3.9%. para 1, 13.8%, para 2+, 16.2%). Stress or mixed incontinence occurred at least weekly in 3% of all the women. After adjusting for age, parity, body mass index, smoking, previous abortions, and previous lower abdominal or urological surgery in a logistic regression model, primiparous women who had delivered vaginally had higher risk of stress or mixed urinary incontinence than nulliparous women (OR 5.7; 95% CI 3.9–8.3). Subsequent vaginal deliveries did not increase the risk significantly. Young age, body mass index > 30, and smoking were possible risk factors for developing urinary incontinence. Obstetric factors: weight of the newborn > 4000 g (OR 1.9; 95% CI 14–3.6) increased the risk of urinary incontinence; mediolateral episiotomy in combination with birthweight > 4000 g also increased the risk (OR 3–5; 95% CI 1.2–10.2); a number of other intrapartum factors did not increase the risk of urinary incontinence.
Conclusions The first vaginal delivery was a major risk factor for developing urinary incontinence; subsequent vaginal deliveries did not increase the risk significantly. Birthweight > 4000 g increased the risk; episiotomy in combination with birthweight > 4000 g also increased the risk.     

Flatus and faecal incontinence: prevalence and risk factors at 16 weeks of gestation

Objective To evaluate the prevalence of anal incontinence at 16 weeks of gestation and to identify possible maternal and obstetrical risk factors.
Design Cross sectional study and cohort study.
Setting Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark.
Participants Cross sectional study: 7557 women attending antenatal care. Cohort study: a subgroup of 1726 pregnant women with one previous delivery at our department.
Results The prevalence of anal incontinence within the preceding year was 8.6%. Incontinence of liquid and solid stools was reported in 2.3% and 0.6%, respectively. Isolated flatus incontinence at least once a week was reported in 4.2%. The risk of flatus incontinence at least once a week was increased with age > 35 years (OR 1.6; 95% CI 1.1–2.4) and with previous lower abdominal or urological surgery (OR 1.5, 95% CI 1.1–2.1) in a logistic regression model controlling for maternal factors. Increasing parity did not increase the risk. The risk of flatus incontinence was increased after anal sphincter tear and birthweight > 4000 g in a logistic regression model controlling for maternal and obstetric variables. Episiotomy was insignificantly associated, while spontaneous perineal tear > 3 cm and a number of other intrapartum factors were not associated.
Conclusion True faecal incontinence is rare among younger women. However, an age > 35 years and previous lower abdominal or urological surgery increased the risk of flatus incontinence in contrast to increasing parity. This suggests that childbirth plays a minor role compared with age. However, when analysing obstetric variables separately, a birthweight > 4000 g, and anal sphincter tears were significant risk factors for flatus incontinence.     

Risk factors for lower urinary tract symptoms in women 40 to 60 years of age

OBJECTIVE: To determine the relationship between lower urinary tract symptoms and possible associated risk factors in women 40-60 years old. METHODS: In a normal population study, 502 women with lower urinary tract symptoms and 742 women with no symptoms (controls) were asked about possible associated factors. RESULTS: Four hundred eighty-seven women (97.0%) with symptoms and 564 controls (76.0%) completed the study. Stress incontinence was associated with parity (primipara odds ratio [OR] 2.2, 95% confidence interval [CI] 1.0, 4. 9; para 2 OR 3.9, 95% CI 1.9, 8.0; para 3 OR 4.5, 95% CI 2.1, 9.5), use of diuretics (OR 2.2, 95% CI 1.2, 3.9), hysterectomy (OR 2.4, 95% CI 1.6, 3.7), and increased body mass index (BMI). Urge incontinence was associated with use of diuretics (OR 4.0, 95% CI 2. 2, 7.1) and BMI. Urgency was associated with parity (primipara OR 1. 9, 95% CI 0.9, 4.2; para 2 OR 3.0, 95% CI 1.5, 5.9; para 3 OR 3.1, 95% CI 1.5, 6.5), use of diuretics (OR 2.7, 95% CI 1.5, 4.7) and BMI. Associations between non-incontinence symptoms (except urgency) and observed factors were weak and inconsistent. Straining at stool and constipation were inversely associated with lower urinary tract symptoms. Overall, lesion of sphincter ani, episiotomy, fetal weight, physical activity, and hormonal status had minor association with lower urinary tract symptoms. CONCLUSION: Lower urinary tract symptoms were associated positively with parity, BMI, prior hysterectomy, use of diuretics, straining at stool, and constipation.     

Impact of Episiotomy During Operative Vaginal Delivery on Obstetrical Anal Sphincter Injuries

ObjectiveThe purpose of this study was to describe associations between episiotomy at the time of forceps or vacuum-assisted delivery and obstetrical anal sphincter injuries (OASIS).MethodsThis population-based retrospective cohort study used delivery information from a provincial perinatal clinical database. Full-term, singleton, in-hospital, operative vaginal deliveries of vertex-presenting infants from April 1, 2006 to March 31, 2016 were identified. Odds ratios (ORs) and 95% confidence intervals (CIs) for associations between episiotomy and third- or fourth-degree lacerations were calculated in multiple logistic regression models (Canadian Task Force Classification II-2).ResultsEpisiotomy was performed in 34% of 52 241 operative vaginal deliveries. OASIS occurred in 21% of forceps deliveries and 7.6% of vacuum deliveries. Episiotomy was associated with increased odds of severe perineal lacerations for vacuum deliveries among women with (OR 2.48; 95% CI 1.96–3.13) and without (OR 1.12; 95% CI 1.02–1.22) a prior vaginal delivery. Among forceps deliveries, episiotomy was associated with increased odds of OASIS for those with a previous vaginal delivery (OR 1.52; 95% CI 1.12–2.06), but it was protective for women with no previous vaginal delivery (OR 0.73; 95% CI 0.67–0.79). Midline compared with mediolateral episiotomy increased the odds of OASIS in forceps deliveries (OR 2.73; 95% CI 2.37–3.13) and vacuum deliveries (OR 1.94; 95% CI 1.65–2.28).ConclusionIn conclusion, results suggest that episiotomy should be used with caution, particularly among women with a previous vaginal delivery and in the setting of vacuum-assisted delivery. Episiotomy may protect against OASIS in forceps-assisted deliveries for women without a prior vaginal delivery.     

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.     

Mode of delivery and fecal incontinence at midlife: a study of 2,640 women in the Gazel cohort

OBJECTIVE: To estimate obstetric risk factors of fecal incontinence among middle-aged women. METHODS: We conducted a mail survey of the Gazel cohort of volunteers for epidemiologic research. In 2000, a questionnaire on anal incontinence was mailed to 3,114 women who were then between the ages of 50 and 61 years; 2,640 (85%) women returned the completed questionnaire. Fecal incontinence was defined by involuntary loss of stool. Logistic regression was used to estimate the effect of obstetric and general risk factors. RESULTS: Prevalence of fecal incontinence in the past 12 months was 9.5% (250). Significant risk factors for fecal incontinence were completion of high school (adjusted odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1-2.0), self-reported depression (OR 2.1, 95% CI 1.6-2.7), overweight or obesity measured by body mass index (BMI) (OR 1.5 for BMI of 25-30, 95% CI 1.1-2.0; OR 1.6 for BMI more than 30, 95% CI 1.1-2.5), surgery for urinary incontinence (OR 3.5, 95% CI 2.0-6.1), and anal surgery (OR 1.7, 95% CI 1.1-2.9). No obstetric variable (parity, mode of delivery, birth weight, episiotomy, or third-degree perineal tear) was significant. Prevalence of fecal incontinence was similar for nulliparous, primiparous, secundiparous, and multiparous women (11.3%, 9.0%, 9.0%, and 10.4%, respectively), and among parous women, it was similar for women with spontaneous vaginal, instrumental (at least one), or only cesarean deliveries (9.3%, 10.0%, and 6.6%, respectively). CONCLUSION: In our population of women in their 50s, fecal incontinence was not associated with either parity or mode of delivery.     

Risk factors for third degree perineal ruptures during delivery

Objective To determine risk factors for the occurrence of third degree perineal tears during vaginal delivery.
Design A population-based observational study.
Population All 284,783 vaginal deliveries in 1994 and 1995 recorded in the Dutch National Obstetric Database were included in the study.
Methods Third degree perineal rupture was defined as any rupture involving the anal sphincter muscles. Logistic regression analysis was used to assess risk factors.
Main outcome measures An overall rate of third degree perineal ruptures of 1.94% was found. High fetal birthweight, long duration of the second stage of delivery and primiparity were associated with an elevated risk of anal sphincter damage. Mediolateral episiotomy appeared to protect strongly against damage to the anal sphincter complex during delivery (OR: 0.21, 95% CI: 0.20–0.23). All types of assisted vaginal delivery were associated with third degree perineal ruptures, with forceps delivery (OR: 3.33, 95%-CI: 2.97–3.74) carrying the largest risk of all assisted vaginal deliveries. Use of forceps combined with other types of assisted vaginal delivery appeared to increase the risk even further.
Conclusions Mediolateral episiotomy protects strongly against the occurrence of third degree perineal ruptures and may thus serve as a primary method of prevention of faecal incontinence. Forceps delivery is a stronger risk factor for third degree perineal tears than vacuum extraction. If the obstetric situation permits use of either instrument, the vacuum extractor should be the instrument of choice with respect to the prevention of faecal incontinence.     

Anal sphincter damage after vaginal delivery: functional outcome and risk factors for fecal incontinence

OBJECTIVE: To assess the role of anal sphincter damage following delivery in the development of anorectal complaints and urinary incontinence, and to identify obstetric factors associated with subsequent fecal incontinence. METHODS: The retrospective cohort study with matched controls used a postal questionnaire and analysis of delivery and operation records from all women who underwent primary repair of a third or fourth degree perineal rupture in our hospital between 1971 and 1991, and their controls, matched for date and parity. Frequencies of complaints were compared using the Mantel-Haenszel common odds ratio [OR] for matched-control studies. Obstetric risk factors for fecal incontinence were assessed with multivariate logistic regression analysis. RESULTS: In the period studied, 171 women underwent a primary repair. One hundred and forty-seven of which returned the questionnaire (86%), compared with 131 of the controls (73%). Analysis was performed on 125 matched pairs with a median follow-up of 14 years. Fecal incontinence was reported by 39 patients and 16 controls (OR: 3.09; 95% confidence interval: 1.57-6.10). Urinary incontinence was reported by 65 cases and 52 controls (OR:1.46; 95% CI: 0.91-2.37). Among women with anal sphincter damage, the extent of anal sphincter damage was an independent risk factor for fecal incontinence. (OR: 2.54; 95% CI: 1.45-4.45). Subsequent vaginal delivery was not associated with the development of fecal incontinence (OR: 2.32; 95% CI: 0.85-6.33). In primiparous women mediolateral episiotomy protected for fecal incontinence after anal sphincter damage (OR: 0.17; 95% CI: 0.05-0.60). CONCLUSIONS: Anal sphincter damage following delivery is significantly associated with subsequent anorectal complaints, but not with urinary incontinence. The extent of sphincter damage is an independent risk factor for the development of fecal incontinence. Mediolateral episiotomy protects for fecal incontinence in primiparous women.     

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.     

Has the use of routine episiotomy decreased? Examination of episiotomy rates from 1983 to 2000

OBJECTIVE: To determine if practice patterns have been altered by the large body of literature strongly advocating the selective use of episiotomy. METHODS: An electronic audit of the medical procedures database at Thomas Jefferson University Hospital from 1983 to 2000 was completed. Univariate and multivariable models were computed using logistic regression models. RESULTS: Overall episiotomy rates in 34,048 vaginal births showed a significant reduction from 69.6% in 1983 to 19.4% in 2000. Significantly decreased risk of episiotomy was seen based upon year of childbirth (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.86, 0.87), black race (OR 0.29, 95% CI 0.28, 0.31), and spontaneous vaginal delivery (OR 0.40, 95% CI 0.36, 0.45). Increased association with episiotomy was seen in forceps deliveries (OR 4.04, 95% CI 3.46, 4.72), and with third- or fourth-degree lacerations (OR 4.87, 95% CI 4.38, 5.41). In deliveries with known insurance status, having Medicaid insurance was also associated with a decreased episiotomy risk (OR 0.59, 95% CI 0.54, 0.64). CONCLUSION: There was a statistically significant reduction in the overall episiotomy rate between 1983 and 2000. White women consistently underwent episiotomy more frequently than black women even when controlling for age, parity, insurance status, and operative vaginal delivery.     

Risk factors for rupture of the anal sphincter

OBJECTIVE: To evaluate risk factors for rupture of the anal sphincter during vaginal delivery. MATERIAL AND METHODS: All 292 parturients with rupture of the anal sphincter in four neighbouring central hospitals in southern Sweden between 1988 and 1990 were identified retrospectively. For each case a control was selected, the sole matching criterion being that the control woman was the next to give birth vaginally in the same unit as the case. Only singleton deliveries were included. For comparison of risk factors among cases and controls, McNemar's test was used for bivariate testing; multiple regression analysis was restricted to those variables found to be significant in the bivariate analysis. Odds ratios (OR) were calculated with 95% confidence limits (CL). RESULTS: In all, 292 of 22,653 deliveries (1.3%) had a rupture of the anal sphincter. Of a total of 14 independent variables explored, 8 were found to be significantly associated with rupture of the anal sphincter in the bivariate testing. In the following multivariate analysis, three variables remained significantly associated with rupture of the anal sphincter: birthweight > or = 4000 g (OR 2.6; CL 1.7, 3.9), primiparity (OR 2.2; CL 1.5, 3.3) and episiotomy (OR 1.7; CL 1.1, 2.6). CONCLUSION: Episiotomy appears to be significantly associated with rupture of the anal sphincter. In contrast to primiparity and birthweight, the incidence of episiotomy during vaginal delivery may easily be reduced. However, only a prospective, controlled study will disclose the true negative or positive effects of episiotomy.     

Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery

Objective  To determine the risk factors for anal sphincter injuries during operative vaginal delivery.
Setting and design  A population-based observational study.
Population  All 21 254 women delivered with vacuum extraction and 7478 women delivered with forceps, derived from the previously validated Dutch National Obstetric Database from the years 1994 to 1995.
Methods  Anal sphincter injury was defined as any injury, partial or complete, of the anal sphincters. Risk factors were determined with multivariate logistic regression analysis.
Main outcome measures  Individual obstetric factors, e.g. fetal birthweights, duration of second stage, etc.
Results  Anal sphincter injury occurred in 3.0% of vacuum extractions and in 4.7% of forceps deliveries. Primiparity, occipitoposterior position and fetal birthweight were associated with an increased risk for anal sphincter injury in both types of operative vaginal delivery, whereas duration of second stage was associated with an increased risk only in vacuum extractions. Mediolateral episiotomy protected significantly for anal sphincter damage in both vacuum extraction (OR 0.11, 95% CI 0.09–0.13) and forceps delivery (OR 0.08, 95% CI 0.07–0.11). The number of mediolateral episiotomies needed to prevent one sphincter injury in vacuum extractions was 12, whereas 5 mediolateral episiotomies could prevent one sphincter injury in forceps deliveries.
Conclusions  Primiparity and occipitoposterior presentation are strong risk factors for the occurrence of anal sphincter injury during operative vaginal delivery. The highly significant protective effect of mediolateral episiotomies in both types of operative vaginal delivery warrants the conclusions that this type of episiotomy should be used routinely during these interventions to protect the anal sphincters.     

Risk factors for female anal incontinence: new insight through the Evanston-Northwestern twin sisters study

OBJECTIVE: To evaluate risk factors for anal incontinence using an identical twin sisters study design to provide control over genetic variance. METHODS: A total of 271 identical twin sister pairs (mean age 47 years) completed the validated Colorectal Anal Distress Inventory questionnaire detailing the presence and severity of anal incontinence. Data were analyzed using a stepwise logistic regression with repeated binary measures to account for correlated data within twin pairs. Three different statistical models were used to analyze nonobstetric as well as obstetric risk factors separately. RESULTS: Significant risk factors for anal incontinence and higher Colorectal Anal Distress Inventory anal incontinence subscale scores included age 40 years or older (fecal: odds ratio [OR] 2.82, 95% confidence interval [CI] 1.21-6.0; flatal: OR 1.90, 95% CI 1.11-3.24), menopause (fecal: OR 2.10, 95% CI 1.15-3.8; flatal: OR 2.11, 95% CI 1.43-3.13), increasing parity (parity > or = 2; fecal: OR 3.09, 95% CI 1.25-7.65; flatal: OR 2.72, 95% CI 1.65-4.51), and the presence of stress urinary incontinence (fecal: OR 2.11, 95% CI 1.12-3.98; flatal: OR 1.72, 95% CI 1.14-2.59). Obesity was associated with significantly higher Colorectal Anal Distress Inventory anal incontinence subscale scores (mean difference 5.18, P = .007). Cesarean delivery after initiation of labor was associated with a lower prevalence of anal incontinence than vaginal birth; however, this difference was not statistically significant (17% compared with 4%, P = .11). No anal incontinence was noted in women who had only elective cesarean deliveries. CONCLUSION: Age, menopause, obesity, parity, and stress urinary incontinence are the major risk factors for female anal incontinence.     

Fecal and urinary incontinence after delivery: risk factors and prevention

OBJECTIVE: This study was undertaken to review the available data on urinary and fecal incontinence and their association with maternal as well as fetal per partum characteristics. METHOD: A Pubmed (Medline search performed between 1999 and 2003 using "urinary incontinence and delivery" and "fecal incontinence and delivery" identified 501 relevant papers. Most of them are retrospective analyses whereas few are randomized controlled trials (RCT). RESULTS: Two studies performed with computer-stored databases analyzed the risk factors of incontinence among 2,886,126 deliveries. Primiparity, birthweight over 4000 g and all types of assisted vaginal deliveries significantly increased the risk of anal sphincter damage. Results concerning the effect of episiotomy are conflicting. Controlled randomized trials have shown that pelvic floor muscle training during pregnancy as well as planned cesarean section significantly and moderately decrease the risk of urinary incontinence. The only RCT available has shown that planned cesarean section did not reduce significantly incontinence of flatus. Finally the only trial that compare surgical techniques used to repair the anal sphincter did not show any significant difference. CONCLUSION: Risk factors for anal sphincter damage during delivery are well known. RCT focusing on how to prevent and how to cure fecal as well as urinary incontinence are urgently needed.     

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.     

The role of maternal age and episiotomy in the risk of anal sphincter tears during childbirth

BACKGROUND: Many women who experience anal sphincter tear will suffer from anal incontinence. The most important tool to avoid this is to recognise the obstetric risk factors involved and thereby prevent injury. AIMS: The aim of this study was to analyse and evaluate the risk factors of anal sphincter tear during delivery. METHODS: Of a total of 57,943 vaginal deliveries, we identified 565 women with partial or total rupture of the anal sphincter and compared these women with 565 controls without sphincter tear with respect to possible risk factors. RESULTS: Several factors were significantly associated with sphincter tears, including nulliparity, birthweight, instrumental delivery, episiotomy, malpresentation, maternal age and epidural analgesia. The importance of these variables was further confirmed in a stepwise logistic regression analysis. Age was found to be a significant risk factor only when the birthweight was less than 4000 g. Episiotomy more than doubled the risk of sphincter tear when delivery was non-instrumental. CONCLUSION: There are several independent risk factors that should be considered when making decisions regarding delivery mode. Maternal age and episiotomy in non-instrumental delivery are two of these.     

Cohort study of maternal and neonatal morbidity in relation to use of episiotomy at instrumental vaginal delivery

OBJECTIVE: The aim of this study was to investigate the maternal and neonatal morbidity related to use of episiotomy for vacuum and forceps deliveries. DESIGN: Retrospective population-based cohort study. SETTING: Dundee, Scotland. POPULATION: Two thousand one hundred and fifty three women who experienced an instrumental vaginal delivery between January 1998 and December 2002. METHODS: Univariate and multivariate logistic regression analyses were performed comparing deliveries with and without the use of episiotomy. MAIN OUTCOME MEASURES: Extensive perineal tears (third and fourth degree) and shoulder dystocia. RESULTS: Two hundred and forty-one (11%) of the 2153 women who underwent instrumental vaginal deliveries did not receive an episiotomy. Vacuum delivery was associated with less use of episiotomy compared with forceps (odds ratio 0.10, 95% CI 0.07-0.14). Extensive perineal tears were more likely with use of episiotomy (7.5%vs 2.5%, adjusted OR 2.92, 95% CI 1.27-6.72) as was neonatal trauma (6.0%vs 1.7%, adjusted OR 2.62, 95% CI 1.05-6.54). Use of episiotomy did not reduce the risk of shoulder dystocia (6.9%vs 4.6%, adjusted OR 1.43, 95% CI 0.74-2.76). The findings were similar for delivery by vacuum and forceps. CONCLUSION: The use of episiotomy increased the risk of extensive perineal tears without a reduction in the risk of shoulder dystocia.     

Urinary tract infections in postmenopausal women: effect of hormone therapy and risk factors.

OBJECTIVE: To assess the effects of hormone therapy on urinary tract infection frequency and to examine potential risk factors. METHODS: We used data from the Heart and Estrogen/Progestin Replacement Study, a randomized, blinded trial of the effects of hormone therapy on coronary heart disease events among 2763 postmenopausal women aged 44-79 with established coronary heart disease. Participants were randomly assigned to 0.625 mg of conjugated estrogens plus 2.5 mg of medroxyprogesterone acetate or placebo and followed for a mean of 4.1 years. History of physician-diagnosed urinary tract infections and risk factors were assessed by self-report at baseline and each annual visit. RESULTS: Urinary tract infection frequency was higher in the group randomized to hormone treatment, although the difference was not statistically significant (odds ratio [OR] 1.16, 95% confidence interval [CI] 0.99, 1.37). Statistically significant risk factors for urinary tract infections in multivariable analysis included: women with diabetes on treatment (insulin OR 1.81, 95% CI 1.40, 2.34), oral medications OR 1.44, 95% CI 1.09, 1.90), poor health (OR 1.34, 95% CI 1.14, 1.57), childbirth (OR 1.38, 95% CI 1.00, 1.90), vaginal itching (OR 1.63, 95% CI 1.07, 2.50), vaginal dryness (OR 1.30, 95% CI 1.04, 1.67), and urge incontinence (OR 1.51, 95% CI 1.30, 1.75). Urinary tract infections in the previous year were strongly associated with a single urinary tract infection (OR 7.00, 95% CI 5.91, 8.29) as well as multiple urinary tract infections (OR 18.51, 95% CI 14.27, 24.02). CONCLUSIONS: Oral hormone therapy did not reduce frequency of urinary tract infections. Potentially modifiable risk factors in postmenopausal women are different from those in younger women, and include diabetes, vaginal symptoms, and urge incontinence.     

Obstetric anal sphincter lacerations

OBJECTIVE: To estimate the frequency of obstetric anal sphincter laceration and to identify characteristics associated with this complication, including modifiable risk factors. METHODS: A population-based, retrospective study of over 2 million vaginal deliveries at California hospitals was performed, using information from birth certificates and discharge summaries for 1992 through 1997. We excluded preterm births, stillbirths, breech deliveries, and multiple gestations. The main outcome measure was obstetric anal sphincter laceration (third and fourth degree). RESULTS: The frequency of anal sphincter lacerations was 5.85% (95% confidence interval [CI] 5.82, 5.88), decreasing significantly from 6.35% (95% CI 6.27, 6.43) in 1992 to 5.43% (95% CI 5.35, 5.51) in 1997 (P <.01). Using logistic regression analysis, we identified primiparity as the dominant risk factor (odds ratio [OR] for women with prior vaginal birth 0.15; 95% CI 0.14, 0.15). Birth weight over 4000 g was also highly significant (OR 2.17; 95% CI 2.07, 2.27). Lacerations occurred more often among women of certain racial and ethnic groups: Indian women (OR 2.5; 95% CI 2.23, 2.79) and Filipina women (OR 1.63; 95% CI 1.50, 1.77) were at highest risk. Episiotomy decreased the likelihood of third-degree lacerations (OR 0.81; 95% CI 0.78, 0.85), but increased the risk of fourth-degree lacerations (OR 1.12; 95% CI 1.05, 1.19). Operative delivery increased the risk of sphincter laceration, with vacuum delivery (OR 2.30; 95% CI 2.21, 2.40) presenting a greater risk than forceps delivery (OR 1.45; 95% CI 1.37, 1.52). CONCLUSION: Anal sphincter lacerations are strongly associated with primiparity, macrosomia, and operative vaginal delivery. Of the modifiable risk factors, operative vaginal delivery remains the dominant independent variable.     

Trends in major modifiable risk factors for severe perineal trauma, 1996–2006

OBJECTIVE: To examine what effect the major modifiable risk factors for severe perineal trauma have had on the rates of this trauma over time. METHODS: A retrospective observational cohort study of singleton vaginal deliveries taken from a perinatal database for the period 1996 through 2006. RESULTS: A total of 46,239 singleton vertex vaginal deliveries met the inclusion criteria. Major risk factors for severe perineal trauma were increased maternal age (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.1-1.5), non-African American ethnicity (OR 1.5, 95% CI 1.3-1.7), nulliparity (OR 4.8, 95% CI 4.11-5.6), fetal birth weight (OR 2.2, 95% CI 1.9-2.4), forceps (OR 8.3, 95% CI 5.4-10.8), vacuum (OR 2.9, 95% CI 1.9-4.4), and midline episiotomy (OR 5.7, 95% CI 5.0-6.4). Evaluation of the changes in rates of these factors over the study period revealed that the decline in the rates of episiotomy and the use of forceps accounted for a reduction in severe lacerations of more than 50%. CONCLUSION: Reduction of severe perineal trauma by restricted use of the 2 modifiable clinical variables, episiotomy and forceps, is evident over time.