Faecal incontinence after childbirth

Britisb Journal of Obstetrics and Gynaecology January 1997, Vol. 104, pp. 4650 Faecal incontinence after childbirth *Christine MacArthur Reader (Maternal and Child Epidemiology), *Debra E. Bick Research Midwife, **Michael R. B. Keighley Professor (Surgery) *Department of Public Health and Epidemiology and **Department of Surgev, Medical School, University of Birmingham, Edgbaston Objective To measure the prevalence and severity of postpartum faecal incontinence, especially new incontinence, and to identify obstetric risk factors. Design A cohort study with information on symptoms collected in homebased interviews and obstetric data from hospital casenotes. Setting Deliveries from a maternity hospital in Birmingham. Participants Nine hundred and six women interviewed a mean of 10 months after delivery. Main outcome measures New faecal incontinence starting after the birth, including frank incontinence, soiling and urgency. Results Thirtysix women (4%) developed new faecal incontinence after the index birth, 22 of whom had unresolved symptoms. Twentyseven had symptoms several times a week, yet only five consulted a doctor. Among vaginal deliveries, forceps and vacuum extraction were the only independent risk factors: 12 (33%) of those with new incontinence had an instrumental delivery compared with 114 (14%) of the 847 women who had never had faecal incontinence. Six of those with incontinence had an emergency caesarean section but none became incontinent after elective sections. Conclusions Faecal incontinence as an immediate consequence of childbirth is more common than previously realised, and medical attention is rarely sought. Forceps and vacuum extraction deliveries are risk factors, with no protection demonstrated from emergency caesarean section. Identification and treatment is a priority. INTRODUCTION Those involved in treating faecal incontinence have long recognised that women commonly report a history of difficult childbirth. It has generally been assumed that whilst the injury occurs at delivery, except in rare cases such as after third degree tear, incontinence symptoms do not appear until many years later. Sleep and Grant2 in a trial of pelvic floor exercises for the treatment of urinary incontinence reported that 3% of 1609 women experienced occasional faecal loss three months after delivery. Sultan et d3 as part of a study of deliveryrelated anal sphincter damage found that 10% of 127 who were delivered vaginally had anal incontinence (including incontinence of flatus) or urgency six to eight weeks later. This sample, however, was small and may not have been representative since it included only those who agreed to have the various anal and perineal assessments. This present paper reports on the prevalence of postpartum faecal incontinence, especially new Correspondence: Dr C. MacArthur, Department of Public Health and Epidemiology, Medical School, University of Birmingham, Edgbaston, Birmingham B I5 2TJ, UK. cases, obstetric risk factors, and medical consultation about symptoms, in a representative sample of 906 deliveries. METHODS The work is part of a larger study of postpartum morbidity and its effect on women s lives4. The population included all women who were delivered between April and September 1992 at a maternity hospital in Birmingham. General practitioners were contacted to check whether there was any reason why any of the women should not be included; 21 exclusions were made and 69 women had moved from the practice. Six to seven months after delivery 1667 women were sent questionnaires and 61 questionnaires were returned by the post office as no longer at the address. Of the 1606 assumed to have received a questionnaire, 1278 were returned (80%). One of the main objectives of this study was to obtain a detailed characterisation of postpartum symptoms, which was not possible from a postal questionnaire. Therefore, the second phase comprised an interview of all symptomatic women and a random sample of the nonsymptomatic conducted by 46 0 RCOG 1997 British Journal of Obstetrics and Gynaecologv

~ ~~ ~ FAECAL INCONTINENCE AFTER CHILDBIRTH 47 midwives in the women s homes. Due to the sensitive nature of faecal incontinence and the consequent likelihood of underreporting, questions on these symptoms were included in the interview rather than the postal questionnaire. Nine symptoms (backache, headaches, neckache, paraesthesias in hands, pain in legs, visual disturbances, dizziness or fainting, stress incontinence and fatigue) were included in the postal questionnaire. The reasons for these choices relates to earlier work on postpartum symptoms and epidural anaesthesia5s6. All women with one or more of these symptoms occurring within three months of the birth and lasting longer than six weeks, were defined as symptomatic and contacted for home interview. Because the frequency of the additional conditions assessed at interview (faecal incontinence, sexual problems and depression) might vary in women already known to have other postpartum symptoms, a random half of the women who had not reported any of the symptoms included in the postal questionnaire were also contacted. Of 1156 women contacted, 906 (78%) were interviewed, 760 from the symptomatic and 146 the nonsymptomatic group. There was, however, no significant difference in the proportion reporting faecal incontinence from these two groups. The obstetric characteristics of the 906 women who were interviewed did not differ significantly from those of the women who were not interviewed or had not responded. The interview took place a mean of 45 weeks (SD 10.1) after the birth. Information from the women was linked to the computerised obstetric casenote data. Approval for the study was given by the South Birmingham Health Authority Research Ethics Committee. RESULTS Faecal incontinence: new and recurrent The questions on faecal incontinence were asked towards the end of the interview to allow the midwifeinterviewer to develop a rapport with the women. Each was asked whether she had had any problems with loss of bowel control: that is, no warning that she needed to go (frank incontinence); soiling or staining of her underwear; or felt the need to go but couldn t hold on (urgency). We did not ask about incontinence of flatus. In total 55 women (6.1%) reported one or more of the above symptoms since the birth of the child: 36 (4%) had never had them before the delivery. These 36 new cases are the main focus of this report. The other 19 women (4 primiparae and 15 multiparae) Table 1. Type of symptoms among women with new incontinence. Symptoms n (%) Faecal urgency only Soiling only Frank incontinence only Urgency and soiling Frank incontinence and urgency All three symptoms had recurrent or ongoing symptoms: seven related to previous births, three with inflammatory bowel disease, seven with imtable bowel syndrome, one with coeliac disease and one currently under investigation. In addition to the 55 with current symptoms, four women had no incontinence following this particular birth but had experienced it in connection with the birth of an earlier child. The remaining 847 women had never had faecal incontinence. Type, onset and duration of new symptoms Among the 36 women with new faecal incontinence, 52 symptoms were described: 23 women had one symptom, 10 had two and 3 had all three symptoms (Table 1). Faecal urgency was reported by 34 women (89%). Most described this as needing to defecate immediately, being unable to delay even for a few minutes. Over a third (1 336%) reported soiling and seven (1 9%) had frank incontinence. The majority of women reported symptom onset as immediate (n = 15), or within the first week or two of the birth (n = 6). In five women symptoms did not start until more than three months after the birth, but three of these five also reported constipation and straining which had started immediately. Most incontinence symptoms were unresolved: when interviewed, 22 women (61%) still had symptoms. Mean duration was 23 weeks. Symptom onset and duration were unrelated: symptoms starting immediately after the birth were no more or less likely to remain unresolved than those starting later. Frequency and severity of symptoms Fourteen women (39%) reported daily symptom occurrence and 13 (36%) reported experiencing symptoms on some days of every week. Severity was assessed using a 100 mm visual analogue scale, the descriptions at each end of the scale being no loss of control and loss of control as bad as I could imagine. The mean score was 50.5 (range 12loo), with nine women giving a score of 75 or more. Only eight women (22%) said that the symptoms affected their lifestyle. 0 RCOG 1997 Br J Obstet Gynaecol 104, 4650

~ 48 c. MACARTHUR ET AL. Table 2. Comparison of maternal and obstetric factors among those with new incontinence and those who have never had incontinence. Values are given as n (%)unless otherwise indicated. Incon = incontinence. Primiparae Multiparae New Incon (n = 18) Never had Incon (n = 345) New Incon (n = 18) Never had Incon (n = 496) No. of previous births 1 2 33 Age 30 or more Induced onset of labour Type of delivery Elective section Emergency section Forceps* Vacuum extraction Spontaneous vaginal Perineal trauma Episiotomy 1st degree tear 2nd degree tear greater** Episiotomy and tear Intact 1st stage labour? 10 h 2nd stage labour? 2 h Active 2nd stage labour 22 h Birthweight 3 4000 g Head circumference? 36 cm 27.9 [5.5] 6 (33.3) 6 (33.3) 9 (60.0) 7 (38.9) 3306 [804.7] 34 [2.3] 94 (27.2) 26.7 [5.2] 49 (14.2) 13 (3.8) 54 (15.7) 81 (23.5) 11 (3.2) 184 (53.3) 125 (36.2) 21 (6.1) 91 (26.4) 16 (4.5) 110 (31.9) 136 (47.1) 99 (285) 41 (11.8) 43 (12.5) 3318.3 [661.3] 84 (24.3) 343 [2.7] 10 (55.6) 7 (38.9) 12 (66.7) 30.9 [4.8] 13 (72.2) 8 (44.4) 3443.9 [435.3] 34.6 [ 1.21 305 (61.5) 115 (23.2) 76 (15.3) 248 (50.0) 29.6 [4.6] 42 (8.5) 48 (9.7) 53 (107) 21 (4.3) 3 (0.6) 366 (74.1) 52 (10.5) 64 (12.9) 113 (22.8) 1 (0.2) 267 (53.8) 79 (19.8) 24 (4.8) 19 (3.8) 41 (8.3) 3431.7 [633.5] 117 (23.6) 34.7 [2.5] *Rotational forceps used in 16 cases, two with incontinence. **There were three third degree tears, none with incontinence. Medical consultation Only five women (14%) had consulted a doctor about their faecal incontinence, even though four more had consulted about other bowel symptoms. The most common reason for not consulting was that the women thought the symptoms would eventually improve, andor that they hadn t had them long enough to go to the doctor. Yet among the 11 who gave this type of response, seven had unresolved symptoms. The next most common reason related to the women s perceived severity of the problem or its effects with such responses as it s not bad enough or I can cope with it. However among the eight giving these responses, five had daily symptom occurrence. Embarrassment (n = 5), all part of having a baby (n = 5) and the doctor can t do anything (n = 2) were also mentioned. Obstetric risk factors In order to examine associations with obstetric factors, symptoms must be relatable to the most recent delivery; therefore all women with previous faecal incontinence were excluded from the analysis. Table 2 compares obstetric characteristics among the women with new faecal incontinence first starting after the birth, and those who had never had faecal incontinence. The information is given separately for women having first and subsequent births. Looking first at vaginal deliveries, logistic regression was carried out entering the factors shown in Table 2 to determine which were independently associated with subsequent symptoms. Vacuum extraction (P = 0.0002) and forceps (P = 0,027) delivery were the only two factors significant at the 95% level, but in view of the relatively small numbers of womk in the incontinence group these findings must be interpreted with caution. Similar analyses with a larger number of symptomatic women are required. Vacuum extraction is infrequently performed in the study hospital, so the handwritten casenotes were examined for all such deliveries to look further at the reasons given for undertaking instrumental intervention, but nothing of note was found. Among the four women with symptoms after vacuum extraction three were primiparae, two of whom had urgency starting soon after delivery which was still unresolved at nine months postpartum. The other primiparae had a single episode of frank incontinence eight weeks 0 RCOG 1997 Br J Obstet Gynaecol 104, 4650

FAECAL INCONTINENCE AFTER CHILDBIRTH 49 after the birth. The multiparous woman had urgency which started five months postpartum and was still present ten months postpartum; she also reported straining with an immediate postpartum onset. Caesarean sections There were no elective caesarean sections in the incontinence group, although this difference was not statistically significant because of small numbers. The proportion delivered by emergency section was similar in both groups. The handwritten casenotes were examined for the six symptomatic women delivered by emergency section, five of whom were primiparae. One woman had had a failed forceps delivery and she developed urgency two weeks after the birth; this remained unresolved at interview 12 months postpartum. Another had been fully dilated, with delay in the second stage and fetal distress; this woman had frank incontinence and urgency, both of which started within two weeks of the birth and was still present 10 months postpartum. The remaining four had not been fully dilated; reasons for caesarean section were given as cephalopelvic disproportion (soiling and urgency with immediate onset, unresolved at 11 months); severe preeclampsia (soiling starting nine weeks postpartum, lasting until five months and resolved after surgery for anal fissure); fetal distress (urgency starting eight months postpartum and still present at 10 months); and fetal distress with maternal pyrexia. The last was a multiparous woman whose earlier birth had also been an emergency caesarean section for fetal distress; her symptoms were soiling which began immediately after the birth and lasted until she was three months postpartum. All except the woman with preeclampsia had been in labour for several hours (range of 610 h) before the caesarean section with cervical dilation ranging from 4 cm to 7 cm. DISCUSSION This study, based on 906 deliveries, has shown that faecal incontinence following childbirth is by no means a rare event: 36 women (4%) reported this as a new postpartum symptom. Seven of the 19 women with recurrent symptoms also described a previous childbirth related history and four more women with no incontinence after this birth had had it after a previous delivery. Had incontinence of flatus been included, as in other work3, prevalence would have been much higher. Among vaginal births, new incontinence was significantly associated with forceps and with vacuum extraction delivery. The mechanisms of causation of childbirthrelated anorectal incontinence have previously been studied by measuring neurological and mechanical injury and relating these measures to obstetric factors317. This present study differs in that it directly relates symptoms of faecal incontinence to obstetric factors. Snooks et al7l8 have published a number of papers focusing on the role of neurological injury of the pelvic floor musculature in urinary and faecal incontinence. They found increased pudendal nerve terminal motor latency, 48 h to 72 h after delivery, was more common after forceps, a prolonged second stage and among multiparae. Only two of the 71 women in the sample reported faecal incontinence, one of whom had also had it beforehands. More recently Sultan et az.399j0 have undertaken several investigations of mechanical damage to the anal sphincter. One study3 assessed 150 women at 34 weeks of gestation and six to eight weeks postpartum. Anal endosonography showed no sphincter defects antenatally among the 79 primiparae delivered vaginally, but at six to eight weeks 35% had defects. Among the multiparae 40% had defects antenatally and 44% at six to eight weeks. The association between sphincter defects and obstetric variables was examined using stepwise logistic regression, which showed that forceps delivery was independently associated with both internal and external sphincter defects. Eight of the ten women delivered by forceps in this study had sphincter defects. In total, 13 women in the study had new faecal incontinence (including flatus and urgency defined as the inability to defer defecation for more than 5 min), and all but one had sphincter defects9. Our own findings support those of this study on the increased risk of faecal incontinence after forceps delivery but differ in relation to vacuum extraction and to caesarean deliveries. In the study by Sultan et al3 none of the five women delivered by vacuum extraction had sphincter defects or symptoms. The same research group undertook another study9 to examine the role of instrumental deliveries in primiparae, comparing 26 forceps, 17 vacuum extraction and 47 unassisted deliveries. After forceps delivery 21 women had anal sphincter defects and 10 (38%) had new defecatory symptoms, as defined earlier; for vacuum extractions four had defects and two (12%) had symptoms. Of women having spontaneous deliveries, 17 had defects and two (4%) had symptoms. Defects were significantly more common after forceps, but for symptoms, although proportionately more common after forceps than vacuum extraction deliveries, the numbers were small and the difference not significant (Fisher s exact test P = 008). In our study the proportionate difference was in the opposite 0 RCOG 1997 Br J Obstet Gynaecol 104, 4650

50 C. MACARTHUR ET AL direction, with more symptoms after vacuum extraction (22%) than forceps (7%), but again the difference was not significant (Fishers Exact Test P = 0.07). Although there are various other reasons why vacuum extraction should be the instrument of choice for operative vaginal delivery"j*, the data from these studies do not allow us to conclude that vacuum extraction differs from forceps delivery in relation to subsequent faecal incontinence. In the study hospital vacuum extraction is rarely used therefore the expertise of the operator must be considered. Even when a procedure becomes routine the degree of skill of the operator may be relevant although almost impossible to measure objectively. More data comparing the relative effects of forceps and vacuum extraction obtained from deliveries of larger groups, especially randomised comparisons, is necessary. Neurological and mechanical damage have been investigated after caesarean section. Snooks et al. * showed no pudendal nerve damage in 14 women after elective section, but Sultan et af. 13, assessing left and right sides separately, found leftsided prolongation of terminal motor latency after caesarean section performed during labour. Anal sphincter damage was not found to occur after elective or emergency sections, but the numbers studied were very small3. None of these studies, nor the present study, have found new faecal incontinence after elective caesarean section, although differences are not statistically significant. Previous studies have found no symptoms after emergency section either, but in this much larger series faecal incontinence was reported following this type of delivery. Among women who are not fully dilated it is possible that labour, especially with cephalopelvic disproportion, can cause pelvic floor trauma and pudendal neuropathy from pressure and stretching: this could be a possible causation mechanism. The effect of emergency caesarean section, however, is still inconclusive. The duration of faecal incontinence was considerable for many women in this sample, often occurring daily or at least several times a week. Yet only five had been to the doctor, a finding compatible with studies of incontinence in the general population3j4j5. Nonconsultation probably accounts for the previous lack of recognition by the medical profession of this problem as an immediate consequence of childbirth. When asked why they had not consulted a doctor, women gave reasons which did not accord with their own reports of symptom duration or frequency. Such responses are more likely to represent post hoc rationalisations following a decision not to consult, probably influenced more by the sensitivity attached to these types of symptoms16. It is now clear that childbirthrelated faecal incontinence is not rare and occurs immediately rather than in years to come. It is more common, but does not exclusively occur, after instrumental deliveries. How long it persists or if it resolves and later recurs has not been studied. While continuing to investigate causation so that as many cases as possible can be prevented, and giving consideration to treatment options, those professionals who provide postpartum care must also ensure that women feel able to report these symptoms. Acknowledgements We would like to thank the women who participated in the study, and Mrs J. Cook, Mrs S. Jones, Mrs C. Maxwell, Mrs C. Parkes and Mrs C. Walker who carried out the interviews. The study was financed in part by a grant from the Department of Health, London. References Swash M. Faecal incontinence. Childbirth is responsible for most cases. BMJ 1993; 307: 63&631. Sleep J, Grant A. Pelvic floor exercises in postnatal care. Br J Midw@y 1981; 3: 158164. Sultan AH, Kamm MA, Hudson CN. et al. Anal sphincter disruption during vaginal delivery. NEnglJMed 1993; 329: 19051911. Bick DE, MacArthur C. The extent, severity and effect of health problems after childbirth. BrJMidwifery 1995; 3: 273 1. MacArthur C, Lewis M, Knox EG, Crawford JS. Epidural anaesthesia and long term backache after childbirth. BMJ 1990; 301: 912. MacArthur C, Lewis M, Knox EG. Investigation of long term problems after obstetric epidural anaesthesia. BMJ 1992; 304: 12791282. Snooks SJ, Swash M, Mathers SE, Henry MM. Effect of vaginal delivery on the pelvic floor: a 5 year follow up. Br J Surg 1990; 77: 13581360. Snooks SJ, Swash M, Setchell M, Henry MM. Injury to innervation of pelvic floor sphincter musculature in childbirth. Lancet 1984; 2: 546550. Sultan AH, Kamm MA, Bartram CI, Hudson CN. Anal sphincter trauma during instrumental delivery. Int J Gynaecol Obstet 1993; 43: 263210. 10 Kamm M. Obstetric damage and faecal incontinence. Lancet 1994; 344: 130733. 11 Vacca A, Keirse MJNC. Instrumental vaginal delivery. In: Chalmers I, Enkin M, Keirse MJNC, editors. Effective Care in Pregnancy and Childbirth, Vol 2. Oxford: Oxford University Press, 1989: 121 61233. 12 Johanson RB, Rice C, Doyle M. ef al. A randomised prospective study comparing the new vacuum extractor policy with forceps delivery. BrJObsfet Gynaecol1993; 100: 524530. 13 Sultan AH, Kamm M, Hudson CN. Pudendal nerve damage during labour: prospective study before and after childbirth. Br J Obstet Gynaecol1994; 101: 2228. 14 Leigh RJ, Turnberg LA. Faecal incontinence: the unvoiced symptom. Lancet 1982; 1: 13491351. 15 Thomas TM, Egan M, Walgrove A, Meade TW. The prevalence of faecal and double incontinence. Comm Med 1984; 6: 216220. 16 A new baby? How wonderful [personal view]. BMJ 1994; 309: 8158 16. Received I1 December 1995 Accepted 4 June 1996 0 RCOG 1997 Br J Obstet Gynaecol 104, 4650