Faecal incontinence after first instrumental vaginal delivery using Thierry

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In the name of Allah
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Fecal incontinence related to pregnancy, vaginal
delivery, and cesarean

• Foroozan Atashzadeh Shorideh
• PhD nursing Candidate, Shahid Beheshti Medical
  University

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• Fecal incontinence has a significance impact on
  quality of life.
• Vaginal delivery is the major risk factor for the
  development of pelvic organ prolapse and urinary
  and fecal incontinence, resulting from damage to
  the pelvic floor muscles, nerves and connective
  tissue.

Bortolini et al 2010
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Definition

• Fecal incontinence refers to the involuntary loss
  of solid or liquid stool.
• Anal incontinence also includes involuntary
  release of flatus.
• The consequences of AI can be detrimental to the
  psychological, social, and sexual wellbeing of
  the patient.

Tin et al , 2010
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Prevalence

• depending on the population studied, the
  definition of type of stool loss, and the
  frequency of episodes

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Causes of Fecal Incontinence
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How does pregnancy affect pelvic floor
dysfunction?

• This is probably the result of the extra weight
  of the uterus and baby on the pelvic floor.

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PREGNANCY AND FECAL INCONTINENCE 

• In studies of nulliparous women, the prevalence
  of fecal incontinence increased from 1 prior to
  pregnancy to 7 during pregnancy.

Chaliha et al 1999, 2001
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Labor and fecal incontinence 

• The risk of fecal incontinence associated with
  second stage of labor appears to be similar to
  the risk of vaginal delivery.

Liebling 2005, Bahl 2004
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vaginal delivery and fecal incontinence

• Controversial
• Anal incontinence was significantly increased
  after spontaneous vaginal delivery compared to
  cesarean delivery (OR 1.32, 95 CI 1.04-1.68).
• The risk of fecal incontinence alone was not
  significantly increased.

Pretlove et al 2008
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Fecal incontinence after first instrumental
vaginal deliveryusing Thierrys spatulas
Parant et al 2010
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• Fecal incontinence was assessed at 2 and 6 months
• postpartum by a questionnaire (Wexner score 5 was
  considered significant)

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Results

• Episiotomy (odds ratio OR5.0) and maternal age
  over 35 years (OR4.1) were independently
  associated with fecal incontinence after
  adjustment.

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Role of anal sphincter laceration 

• In women with obstetric anal sphincter injuries
  (OASIS), the risk of subsequent fecal
  incontinence is estimated to be 9 to 28 percent.

Pollack et al 2004
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Vaginal delivery or cesarean?

• vaginal delivery (76) was associated with a
  greater risk of fecal incontinence compared with
  cesarean delivery (24 ), if the delivery
  conferred a laceration or required
  instrumentation.

Guise et al 2009
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Operative vaginal delivery 

• Operative vaginal delivery is a risk factor for
  anal sphincter laceration and other pelvic floor
  disorders.
• This risk is further increased if the fetus is in
  the occipital posterior position.
• The risk of OASIS appears to be higher in forceps
  deliveries than in vacuum-assisted delivery.

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Type of episiotomy

• Median
• Mediolateral episiotomy

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Birth weight 

• an odds ratio of 1.47 for a sphincter laceration
  with each 500 g increase in fetal birth weight

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Prolonged second stage of labor 

• exceeds 60 minutes

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Maternal birth position 

• standing, squatting or lithotomy positions

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Maternal age 

• As an example, an observational study of women
  reported an increase in odds ratio of 1.09 per
  year of maternal age (95 CI 1.06-1.12).

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Role of neural injury 

• Major risk factors for nerve damage associated
  with childbirth are forceps delivery, length of
  second stage of labor, and increasing birth
  weight.

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Role of time since delivery 
6.4 5 years after vaginal delivery
10 18 years after vaginal delivery
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Clinical manifestations and diagnosis

• Fecal and anal incontinence
• Medical history 
• Occult anal sphincter laceration (endoanal
  ultrasound)
• Physical examination  (inspection of the perianal
  area and vagina and a digital rectal examination)

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Diagnostic procedures 

• endoanal ultrasound
• anorectal manometry
• pudendal nerve terminal latency measurement
• defecography
• electromyography

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Function Anorectal manometry in fecal
incontinence
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Electrophysiologic tests

• EMG needle electrodes into the superficial
  portion of the external sphincter or puborectalis
  muscle myoelectric activity
• Pudendal nerve terminal motor latency measures
  the delay between the application of an
  electrical stimulus and external sphincter muscle
  response. Prolonged pudendal neuropathy

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Defecography

• Videodefecography barium thickened to the
  consistency of stool is introduced into the
  rectum.
• Evacuation is monitored with flouroscopy
• Assessment of the anorectal angle at rest and
  during defecation
• Excessive perineal descent, failure of the
  puborectalis muscle to relax, rectocele and
  internal intususception

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Anal Endosonography

• An ultrasound probe is placed in the anal canal
  or transvaginally to detect sphincter injuries
  and to evaluate pelvic floor structures.

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Anatomy Rectal Ultrasound
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Anatomy Endoanal Coil MRI
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Treatment

• Medical therapy
• Biofeedback
• Surgery

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Treatment

• Improving stool consistency
• Increase intake of bulking agents bran,
  psyllium
• Antidiarrheal agents loperamide, lomotil,
  cholestyramine

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• Bowel management
• Fecal disimpaction
• Scheduled toileting
• Glycerin suppositories daily, 30 min postprandial
• Attempt to defecate at the same time daily
• Daily tap water enema

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Biofeedback

• Biofeedback therapy inexpensive, quick and safe
  option
• Success dependent on the expertise of the
  clinician and the motivation and the ability of
  the patient to understand and cooperate
• Dementia, absent rectal sensation, inability to
  contract the external sphincter are the least
  likely to respond

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Biofeedback

• 70 restoring continence
• 90 reduction in incontinent episodes
• Best outcome after anorectal surgery
• Lowest success spinal cored injury

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Is there a sound scientific basis for the claim
that having an elective c-section protects the
pelvic floor?
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Does perineal massage prevent fecal incontinence? 
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What is the best mode of delivery in women with a
history of anal sphincter laceration or fecal
incontinence? 
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• Will elective c-section prevent sexual
  dissatisfaction during intercourse or uterine
  prolapse?

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• Are there any circumstances when I might wish to
  consider elective c-section?

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