Managing the active stage of second stage labor and the risk of urinary and anal incontinence

According to a recent study published in Not affected. Journal of the American College of Obstetricians and Gynecologists.

Take-out

• Among women who give birth under epidural analgesia, the risk of urinary or anal incontinence 6 months after delivery is not affected by moderate or intensive straining effort.
• Between 6 weeks and 1 year postpartum, a significant proportion of women experience urinary and anal incontinence, and pregnancy and vaginal delivery are associated with an increased risk of pelvic floor disease.
• During the second stage of labor, the baby’s head compresses the pelvic floor, which is associated with potential pudendal nerve stretch and injury, which may contribute to pelvic floor dysfunction.
• In this study, an analysis planned as part of the Phase Active du Second STade trial was conducted to determine the effects of moderate and intensive straining on urinary and anal incontinence in women receiving epidural analgesia. It was carried out.
• Research shows that there is no significant association between moderate or intense straining during the second stage of labor and urinary or anal incontinence, and midwives should be encouraged to teach women the optimal straining techniques. It was suggested that this should be done.

From 6 weeks to 1 year postpartum, 10% to 63% of women are affected by urinary incontinence and 3% to 10% by anal incontinence. Pregnancy and vaginal delivery are associated with an increased risk of pelvic floor disease, but the mechanisms behind this association are still debated.

During the second stage of labor, the baby’s head presses on the pelvic floor, stretching and potentially damaging the pudendal nerve. Multiple hypotheses discuss the association between different types of management of the active phase of second stage labor and pelvic floor muscles, urinary incontinence, and anal incontinence.

There is a lack of information about the effects of moderate or intensive straining on urinary and anal incontinence. To determine the association between these factors at 6 months postpartum, researchers conducted a planned analysis of the secondary objectives of her Phase Active du Second STade (PASST) trial.

The PASST trial was a multicenter randomized controlled trial conducted from January 2017 to May 2020. Participants included nulliparous women aged 18 years and older receiving epidural analgesia for spontaneous or induced labor with a full-term singleton fetus in the upright position. Only women who received epidural analgesia were included to guide evacuation efforts during labor.

Exclusion criteria included mental illness or other illnesses that would affect expulsion, no medical insurance, scars from uterine surgery, inability to speak or understand French, small fetus for gestational age, and congenital abnormalities. , heart rate abnormalities before randomization, and intrauterine death. .

Participants in the moderate straining group were asked by their midwives to limit their straining to two times during each contraction. These women took a break at least every five of their contractions, and there was no limit to the duration of straining.

In the intensive straining group, patients were asked by the midwife to strain three times during each contraction. This group did not include a break and 30 minutes later, surgical birth was discussed between the midwife and obstetrician.

Maternal incontinence at 6 months postpartum was the primary outcome of the analysis and was assessed using the International Consultation on Incontinence-Urinary Incontinence Short Form (ICIQ-UI SF). The ICIQ-UI SF assessed the frequency, severity, and impact on quality of life of urinary incontinence.

ICIQ-UI SF scores range from 0 to 21, with higher scores indicating greater severity. Mild incontinence is measured by a score of 1-5, moderate incontinence 6-12, severe incontinence 13-18, and very severe incontinence 19-21.

The Wexner score was used to assess anal incontinence with a score range of 0–20. A score of 0-4 indicates mild incontinence, 5-9 moderate, 10-16 severe, and 17-20 very severe incontinence. Urinary incontinence was determined by an ICIQ-UI SF score of 1 or higher, and anal incontinence was determined by a Wexner score of 2 or higher.

The final analysis included 890 patients and had similar characteristics between the moderate and intense push groups. Perineal rehabilitation was reported in 84.1% of the moderate strain group and 84.7% of the intensive strain group.

No association was found between moderate or intense straining and urinary or anal incontinence. ICIQ-UI SF scores of 1 or higher were reported by 36.6% of the moderate strain group and 38.5% of the severe strain group. The proportion of Wexner scores ≥2 in these groups was 32.2% and 34.6%, respectively.

Severe urinary and anal incontinence, defined by higher ICIQ-UI SF and Wexner scores, also did not differ between groups. Double incontinence was only reported in 14.6% of the moderate straining group and 16.2% of the intensive straining group.

These results indicate that in women receiving epidural analgesia, urinary and anal incontinence is not affected by management of the active phase of second stage labor. The researchers concluded that midwives should guide women in using the straining techniques that are most effective for them.

reference

Dupuis N, Pizzoferrato A, Garabedian C, Chantry A, Le Ray C. Moderate or intensive management of active phase of second stage labor and risk of urinary and anal incontinence: Results of the PASST randomized controlled trial. Journal of the American College of Obstetricians and Gynecologists. 2023;229(5):528.E1-528.E17. doi:10.1016/j.ajog.2023.07.034