Failure to Void in Labour: Postnatal Urinary and Anal Incontinence by Linda Birch, Patrick M Doyle, Roger Ellis and Elaine Hogard

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TRAUMA IN CHILDBIRTH Failure to void in labour: postnatal urinary and anal incontinence By Linda Birch, Patrick M Doyle, Roger Ellis and Elaine Hogard

2.8% (Arya et al, 2001) to 77% (Sampselle et al, 1996). This Abstract wide variation may be explained by differing research meth- ods. Some studies use urodynamic assessment; others use a The objectives was to identify the impact of intrapartum voiding self-reported questionnaire. Some include multiparous and on postnatal urinary and anal incontinence. A longitudinal, primiparous women while others, such as this one, focus on prospective, repeated measures, cohort study design was used. primiparous women only. The time that the patient is asked The study was set in one of the biggest and busiest acute NHS about their symptoms can vary from a few days postnatally to university teaching hospitals in the North West of England, which several years, so it is difficult to compare studies. provides maternity care to over 4000 women each year. Persistent postnatal urinary incontinence is often attrib- Primiparous women with no pre-existing disease (n=516) uted to pathophysiological changes consequential to labour participated and were recruited after a normal 20-week gestation and delivery. In addition to trauma to the bladder, urethra obstetric ultrasound scan. and supporting structures, denervation of the pelvic floor and Data was collected using validated questionnaires during the perineal muscle injury are thought to directly contribute to last trimester of pregnancy and postnatally at six weeks, six postnatal urinary incontinence. months and finally at one year. Obstetric and demographic data During vaginal delivery, the endopelvic fascia and leva- was extracted from case notes. This included age, body mass tor ani muscles may become traumatised. In addition, the index, gestation, duration of labour, analgesia, birth weight, nerve supply to the levator musculature, i.e. the pudendal mode of delivery and perineal trauma. Statistical analysis was nerve, may suffer stretch injury leading to denervation. The undertaken using Statistics Package for Social Sciences (SPSS result may lead to stress incontinence (Freeman, 2002). version 13.0). MRI scanning (Tunn et al, 1999; Kearney et al, 2006) and The main outcome measures were urinary incontinence electromyography (EMG) studies (Weidner et al, 2006) symptoms and anal incontinence symptoms. Prolonged periods of have both confirmed levator defects in primiparae following time in labour without emptying the bladder was associated with vaginal delivery. increased rates of postnatal urinary incontinence (OR 2.36) and This has led to the assertion that a caesarean section will may also contribute to anal incontinence. have a protective effect. Data identifying obstetric risk fac- Postnatal urinary incontinence may be reduced if intrapartum tors and consequential perineal and nerve damage remain bladder care policies reflect frequent emptying. This preliminary contradictory. The pathophysiology of urinary inconti- data supports large-scale exploration of the association between nence remains unclear but pregnancy itself seems to be a postnatal anal incontinence and bladder emptying in labour. considerable risk factor. The autonomic innervation of the bladder and urethra can degenerate during pregnancy and the regeneration after each delivery appears to be incom- regnancy and childbirth are established risk fac- plete (Owman 1981; Grandadam et al, 1999; Bakircioglu tors for the development of urinary incontinence. et al, 2000). Traumatic stretching and compression of the PIncontinence during the initial few weeks after deliv- peripheral nerve supply to the pelvic floor is associated ery is frequently transient and often destined to subside with pregnancy, labour and delivery and may result in par- as hormonal and pressure effects resolve. Within the first tial denervation of the striated muscle in and around the postnatal year, rates of urinary incontinence range from urethra, leading to urinary dysfunction and incontinence (Handa et al, 1996). Linda Birch is Head of Midwifery and Gynaecology, Women’s and Results of many epidemiologic studies (Jolleys, 1988; Children’s Division; Patrick M Doyle is Consultant Obstetrician Persson et al, 2000; Farrell et al, 2001; Goldberg et al, 2005; & Urogynaecologist, Wirral University Teaching Hospital NHS Van Brummen et al, 2007) and pathophysiological studies Foundation Trust, Wirral; Professor Roger Ellis is Professor of (Snooks et al, 1990; King and Freeman 1998) assessing Social and Health Sciences, Director of Research Policy and risk factors for incontinence have been largely inconclusive, Associate Dean Research and Development, Chester University, often presenting contradictory conclusions. However, from Chester; Professor Elaine Hogard is Reader in Evaluation the evidence available, some risk factors for the develop- Research and Leader of Social and Health Evaluation Unit, Social ment of urinary incontinence in an obstetric population can and Health Evaluation Unit, Chester University, Chester be identified, for example, raised body mass index (BMI), Email: [email protected] vaginal delivery, and instrumental delivery. Other risk factors remain controversial. These include smoking, age, diet,

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increased parity, total labour duration, length of second stage of labour, fetal size, and genital tract trauma. Further respondents who did not potential risk factors, such as voiding in labour, have not been explored. empty their bladder for more Prevalence of anal incontinence among postnatal women than four hours prior to varies between 1% and 21% (Johanson and Lafferty 1996; ‘ Boreham et al, 2005). As with studies looking at urinary beginning the second stage symptoms, there are problems with definition, method, clas- sification and sample selection. Higher rates were recorded by of labour were ... more studies using longer term follow-up; with 22–30.5% reporting anal incontinence at one-year postnatal (Fynes et al, 1999; likely to report any urinary Van Brummen et al, 2006). incontinence ... Anal sphincter damage is a recognized risk factor for postnatal anal incontinence. Recent studies have found evidence of postnatal occult anal sphincter damage in 7–28% of primiparous women (Abramowitz et al, 2000; regarding the care received and progress of labour. This Faltin et al, 2000; Andrews et al, 2005; Nichols et al, included age, gestation, BMI, onset,’ progress and duration 2006) with one study demonstrating 19% of primiparous of labour, analgesia, birth weight, mode of delivery and women who were classed as having a first- or second- perineal trauma. degree tear having an anal sphincter defect on endo-anal scan (Nichols et al, 2006). Analysis Statistical analysis was undertaken using Statistics Package for Method Social Science (SPSS version 13.0). Variables were analysed as This longitudinal prospective study collected data from continuous scales, incremental scales and percentile groups of primiparous patients during the last trimester of pregnancy, approximately equal size. and also postnatally at six weeks, six months and one year, using the Kings Health Incontinence Questionnaire (Kelleher Ethical approval et al, 1997). The Kings Health Questionnaire is a validated Ethical approval was granted by the Local Research Ethics tool used to assess urinary incontinence and its impact on Committee for Wirral. quality of life. It explores perception of general health and the perceived impact of incontinence on aspects of life. This Results is followed by a symptom index where patients are asked to Following exclusions owing to severe maternal or fetal illness indicate how often they are experiencing urinary symptoms 1023 women offered full participation. A total of 862 women on a three-point scale (a little; moderately; a lot). The remain- (84.1%) agreed to participate in the study. ing items explore the impact of urinary incontinence on Of the 862 women recruited (59.9%) 516 returned at quality of life. Finally, questions are included which explore least 2 of the 3 postnatal questionnaires and are included in behaviour undertaken to address the continence problem, postnatal data analysis. Women only returning 1 postnatal such as wearing pads, alteration to diet and embarrassment. questionnaire (n=237; 27.5%) were excluded from data This section forms a severity score. Given that the same ques- analysis due to incompleteness. Of the 516 postnatal data sets tionnaire was given to the same patients, on three occasions analysed, 404 (78.3%) women completed the questionnaire over the course of the postnatal year, it was also possible to determine if incontinence was progressive—getting worse, or Table 1. Symptoms reported regressive—getting better. At one-year postnatal, participants were also asked to Antenatal 6 weeks 6 months 1 year report anal incontinence symptoms using the Manchester % (n=466) % (n=404) % (n=397) % (n=336) Health Questionnaire (Bugg et al, 2001). This mirrors the Kings Health Questionnaire but explores anal incontinence Frequency of micturition 72.3 34.6 36.6 23.8 symptoms. Nocturia 76.2 35.6 35.1 21.7 In order to reduce obstetric and social variables, the research only recruited women who had no previous children Urgency 37.3 22.8 23.6 20.2 and were not suffering from any medical condition that may Urge incontinence 23.5 21.2 21.4 16.4 predispose them to continence problems. Stress incontinence 39.7 28.2 31 26.5 In addition to the questionnaires, intrapartum and delivery data were obtained from maternity case notes. In Nocturnal enuresis 5.6 4.9 4.8 1.8 order to improve accuracy and detail of the information Intercourse incontinence 6.8 6.4 6.4 3.9 gathered, each handwritten account of delivery information was examined in detail. The patient computerized record Frequent infection 14.6 10.1 9.6 6.6 of care was also accessed. Information collected included Bladder pain 16.1 9.7 12.2 7.5 demographic and obstetric details, as well as information

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45% perceived their condition to be getting worse. 50 At one year postnatally, 336 women returned a complete questionnaire. No urinary symptoms were reported 40 by 62% (n=208) of the women who replied. The remaining 38% had a variety of symptoms. Stress incontinence 30 was the most common reported symptom. In total, 11% (n=37) of women completing this one-year questionnaire 20 reported new onset of urinary incontinence. New onset urge incontinence was reported by 3.9% (n=13), new onset stress incontinence by 4.5% (n=15) and new onset of both 10 urge and stress incontinence by 2.7% (n=9). As found at the six-month postnatal questionnaire, many women reporting % reporting stress incontinence 0 0-2 2-4 4-6 6-8 >8 new symptoms perceived their condition to be the same or better than before. Hours from bladder emptying to commencement of the At one year postnatally, anal incontinence was reported by second stage of labour 9.3% (n=31) of the 336 respondents. Figure 1. Stress incontinence at one year postnatal Bladder emptying in labour Data on bladder emptying in labour was extracted from case at six weeks postnatally; 397 (76.9%) completed the six- notes, and subjects were divided in to two-hourly incremen- month postnatal questionnaire and 336 (65.1%) completed tal time bands representing voiding time before the onset of the 1-year postnatal questionnaires. the second stage of labour. Those respondents who had an emergency caesarean section in the first stage of labour were Symptom prevalence and severity excluded from this part of the data analysis. Respondents were given descriptions of various symptoms Analysis using Chi Square revealed that bladder emptying and asked to indicate which they were experiencing and how before the start of the second stage of labour was statistically often. Specifically, data was collected relating to frequency or significant for urinary incontinence. Those respondents who urgency of micturition, nocturia and nocturnal enuresis, urge had not had their bladder emptied for more than four hours and stress incontinence, intercourse incontinence, urinary prior to commencement of the second stage of labour had: infection and bladder pain. Findings relating to symptom n Higher rates of ‘any’ incontinence at six weeks postnatal reporting are summarized in Table 1. (x2=4.598; 1df; p=.032; Cramer’s V=.130) Antenatal data analysis is based on replies from 466 n Higher rates of ‘any’ incontinence at six months postnatal women. No urinary symptoms at all were reported by 17.4% (x2=3.843; 1df; p=.05; Cramer’s V=.122) (n=81). The remaining 82.6% (n=385) had a variety of n Higher rates of any incontinence at one year (x2=5.202; symptoms. Nocturia and frequency were the most common 1df; p=.023; Cramer’s V=.154) reported symptoms—as expected in the antenatal period, n Increased stress incontinence at one year (x2=10.663; 1df, with many of the women affected by this ‘a lot’. p=.001; Cramer’s V=.221). At six weeks postnatal, 404 women returned complete In other words, those respondents who did not have their questionnaires. No urinary symptoms were reported by bladder emptied for more than four hours prior to the start 45% (n=182). The remaining 55% had a variety of symp- of the second stage of labour, were 1.94 times more likely toms. Nocturia and frequency remain the most common, to report ‘any’ urinary incontinence and 2.36 times more however, much less was experienced than the rates reported likely to report stress incontinence at one year postnatally, antenatally. based on probability analysis. This result was independent At six months postnatal, 397 women returned a com- of mode of delivery. plete questionnaire. No urinary symptoms were reported Further analysis using Kruscal-Wallis (non-parametric by 44% (n=176). The remaining 56% had a variety of statistical test) explored the relationship between bladder symptoms. Nocturia and frequency being the most com- emptying prior to the second stage of labour and urinary mon. There was also a high level of stress incontinence incontinence severity scores. Those respondants who did reported. In total, 15.3% (n=61) of women completing not empty their bladder for six hours or more before com- this six-month questionnaire reported new onset of urinary mencement of the second stage of labour reported greater incontinence. New onset urge incontinence was reported incontinence severity scores (H[3]=7.903; p=.043; 99% CI by 4.0% (n=16), new onset stress incontinence by 7.5% .037–.048). The result was still statistically significant when (n=30) and new onset of both urge and stress incontinence reduced to four hours without voiding (H[2]=7.902; p=.019; by 3.8% (n=15). Women were also asked if they perceived 99% CI .017–.024). their bladder problem to be getting better, getting worse or Further analysis using Spearman rho (non-parametric staying the same. The majority of women (84%) reporting statistical test) supported the correlation between duration new onset stress incontinence at six months postnatally per- of labour without voiding as a continuous time variable and ceived their condition to be the same or better than before. incontinence severity score as measured on the Kings Health However, of those reporting new onset urge incontinence Questionnaire (r=.24; n=264; p=.045).

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Duration of bladder emptying prior to the start of the second stage of labour also correlated with anal incontinence with those not emptying their bladder for six hours or more prior to commencement of the second stage of labour reporting significantly higher rates of anal incontinence (x2=11.066; 4df; p=.026; Cramer’s V=.198). Repeated analysis comparing spontaneous voiding and catheterization demonstrated that the rates of incontinence were not affected by the mode of bladder emptying. Figure 1 shows the progressive increase in reported stress incontinence associated with increased time since the bladder was emptied. Discussion No previous studies have recorded bladder emptying in labour. Although urine production decreases during labour as a physiological response to stress, other compound- ing factors need to be considered. For example, the use of intravenous fluids when an epidural is cited or when labour is induced/augmented with oxytocin may coun- teract this physiological oliguria. In addition, bladder capacity is further reduced and the bladder itself may be compressed by the fetus. Those respondents who did not empty their bladder for more than four hours prior to beginning the second stage of labour were 1.94 times more likely to report any urinary incontinence and 2.36 times more likely to report stress incontinence at a year postnatally. The mechanism for this is not clear, but it could be related to defective urethral sphincter closure as a consequence of bladder compression and neu- rophysiological compromise. It would appear that the longer the bladder was exposed to these conditions, the more severe was the resulting urinary dysfunction. These results support a reconsideration of midwifery and obstetric practice. While currently women in labour are encouraged to empty their bladder, should they fail to do so intervention by way of insertion of a urinary catheter is not normally initiated unless the bladder is palpable abdominally. This manual examination of the abdomen to determine urine volume in the bladder is by no means accu- rate. Given the long-term sequelae outlined here when the bladder is not emptied for longer periods of time in labour, there is a strong case for advocating routine insertion of a urinary catheter should the woman be unable to void, particularly when factors which increase urine production as listed are present. Those respondents not emptying their bladder for more than six hours prior to delivery also reported significantly higher rates of anal incontinence at one year postnatally. No previous studies have explored bladder emptying in labour as a risk factor for anal incontinence. The precise mechanism for this phenomenon is not known, although it may be related to pelvic floor musculature damage, or neurological pathways being disrupted secondary to pressure injury. Given the small number of respondents with anal incontinence, a change in current practice is not supported. However, large-scale studies that include the exploration of these variables are clearly suggested by these preliminary findings.

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of pregnancy and delivery on the function and ultrastructure of the rat bladder and urethra BJU Int 85: 350–61 Key Points Boreham MK, Richter HE, Kenton KS, Nager CW, Gregory WT, n The majority of women will experience antenatal urinary Aronson MP, Vogy V Y et al (2005) Anal incontinence in women symptoms. presenting for gynecologic care: Prevalence, risk factors, and impact upon quality of life Am J Obstet Gynecol 192: 1637–42 n For a large proportion of these women, symptoms will still Bugg G, Kiff E, Hosker G (2001) A new condition-specific health- persist one year postnatally. related quality of life questionnaire for the assessment of women n While some risk factors for urinary incontinence have been with anal incontinence BJOG 108(10): 1057–67 established, others remain controversial and some have yet to Faltin DL, Boulvain M, Irion O, Bretones S, Stan C, Weil A (2000) be identified. Diagnosis of anal sphincter tears by postpartum endosonography to n This data suggests that urinary incontinence, particularly predict faecal incontinence Obstet Gynecol 95: 643–7 Farrell SA, Allen VM, Baskett TF (2001) Parturition and urinary persistent and worsening stress incontinence is related to a incontinence in primiparas Obstet Gynecol 97(3): 350–6 failure to void frequently during labour. Freeman RM (2002) The effect of pregnancy on the lower urinary tract n While midwifery practice aims to reduce intervention, this and pelvic floor. In: MacLean AB, Cardozo L (eds) Incontinence in needs to be balanced against known risk factors and action women RCOG Press, London: 331–45 should be taken to empty the bladder if spontaneous voiding Fynes M, Donnelly V, Bechan M, O’Connell PR, O’Herlihy C (1999) Effect of second vaginal delivery on anorectal physiology and faecal does not occur. continence: a prospective study. Lancet 354(9183): 983–6 Goldberg RP, Abramov Y, Botros S, Miller JJ, Gandhi S, Nickolov A, Sherman W, Sand PK (2005) Delivery mode is a major environ- mental determinant of stress urinary incontinence: Results of the Evanston-Northwestern twin sister study Am J Obstet Gynecol 193: Conclusion 2149–53 Length of time in labour without voiding has been identi- Grandadam F, Lluel P, Palea S, Martin DJ (1999) Pharmacological and fied as a significant risk factor, not only for the develop- urodynamic changes in the rat urinary bladder function after multi- ment of urinary incontinence, but also a deterioration of ple pregnancies BJU Int 84: 861–6 Handa VL, Harris TA, Ostergard DR (1996) Protecting the pelvic symptoms over time. These findings present implications floor: obstetric management to prevent incontinence and pelvic for midwifery practice, policy and education advocating organ prolapse Obstet Gynecol 88: 470–8 an interventionist, proactive approach to bladder care dur- Johanson JF, Lafferty J (1996) Epidemiology of fecal incontinence: the ing all stages of labour. Obstetric and midwifery policies silent affliction Am J Gastroenterol 91(1): 33–6 should be developed to reflect this. It is recommended Jolleys JV (1988) Reported prevalence of urinary incontinence in women in a general practice BMJ 7(296): 1300–2 that women with an intravenous infusion or a large oral Kearney R, Miller JM, Ashton-Miller JA, DeLancey JO (2006) intake of fluid, empty their bladder at least every four Obstetric factors associated with l;evator ani muscle injury after hours during labour. Should they be unable to do this vaginal birth Obstet Gynecol 107(1): 144–9 spontaneously, consideration should be given to cath- Kelleher CJ, Cardozo LD, KhullarV, Salvatore S (1997) A new questionnaire to assess the quality of life of urinary incontinent women eterization. This finding also presents educational issues BJOG 104(12): 1374–9 for both midwifery and obstetric personnel. Educational King JK, Freeman RM (1998) Is antenatal bladder neck mobility a risk programmes need to be adapted in order to highlight the factor for post partum stress incontinence? BJOG 105: 1300–7 importance of bladder emptying, not only on obstetric Nichols CM, Nam M, Ramakrishnan V, Lamb EH, Currie N (2006) Anal sphincter defects and bowel symptoms in women with and outcomes as is the case now, but also on the long-term without recognized anal sphincter trauma Am J Obstet Gynecol 194: morbidity that can result if voiding for prolonged periods 1450–4 of time does not occur. BJM Owman C (1981) Pregnancy induced degenerative and regenerative changes in the autonomic innervation of the female reproductive tract Ciba Found Symp 83: 252–79 Persson J, Wolner-Hanssen P, Rydhstroem H (2000) Obstetric risk factors for stress urinary incontinence: a population base study. Obstet Acknowledgments Gynecol 96(3): 440–5 All four authors have been involved in the design, completion analysis and Sampselle CM, DeLancey JO, Ashton-Miller JA (1996) Urinary incon- writing of this research.We would like to thank all the women who participated tinence in pregnancy and post partum Neurol Urodyn 15: 329–30 in this research for their honesty and time in completing the questionnaires. Snooks SJ, Swash M, Mathers SE, Henry MM (1990) Effect of vaginal delivery on the pelvic floor: a 5 year follow up Br J Surg 77(12): Disclosure of interest 1358–60 This research has been conducted as part of a larger PhD study. There are no Tunn R, Delancey JO, Howard D, Thorp JM, Ashton-Miller JA, Quint conflicting interests. LE (1999) MR imaging of levator ani muscle recovery following vaginal delivery Int Urogynecol J Pelvic Floor Dysfunct 10(5): 300–7 Van Brummen HJ, Bruinse HW, Van De Pol G, Heintz PM, Van Der Abramowitz L, Sobhani I, Ganansia R, Vuagnat A, Benifla JL, Darai E, Vaart CH (2006) Defecatory symptoms during and after the first Madelenat P et al (2000) Are anal sphincter defects the cause of anal pregnancy: prevalences and associated factors. Int Urogynecol J Pelvic incontinence after vaginal delivery? Results of a prospective study. Floor Dysfunct 17: 224–30 Dis Colon Rectum 43(5): 590–6 Van Brummen HJ, Bruinse HW, Van De Pol G, Heintz PM, Van Andrews V, Sultan AH, Thakar R, Jones PW (2005) Occult anal Der Vaart CH (2007) The effect of vaginal and cesarean delivery sphincter injuries - myth or reality? BJOG 113: 195–200 on lower urinary tract symptoms: what makes the difference? Int Arya L, Jackson N, Myers D, Verma A (2001) Risk of new-onset uri- Urogynecol J 18: 133–9 nary incontinence after forceps and vacuum delivery of primiparous Weidner AC, Jamison MG, Branham V, South MM, Borawski KM, women Am J Obstet Gynecol 185(6): 1318–26 Romero AA (2006) Neuropathic injury to the levator ani occurs in 1 Bakircioglu ME, Sievert KD, Lau A, Lin CS, Lue TF (2000) The effect in 4 primiparous women Am J Obstet Gynecol 195(6): 1851–627

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