Conor O'Brien

A randomised clinical trial comparing the effects of delayed versus immediate pushing with epidural analgesia on mode of delivery and faecal continence

Objective To assess the effects of delayed vs immediate pushing in second stage of labour with epidural analgesia on delivery outcome, postpartum faecal continence and postpartum anal sphincter and pudendal nerve function.

Patterns of abnormal pudendal nerve function that are associated with postpartum fecal incontinence

OBJECTIVE The purpose of this study was to assess patterns of abnormal pudendal nerve function in women who complain of postpartum fecal incontinence. STUDY DESIGN During a 12-month period, a cohort of 83 women underwent neurophysiologic assessment as part of an evaluation of fecal incontinence after vaginal delivery. Pudendal nerve assessment consisted of the measurement of the clitoral-anal reflex and quantitative electromyography of the external anal sphincter. Endoanal ultrasound examination and anal manometry were also performed in each patient. RESULTS Thirty of 83 women (38%) with fecal incontinence were found to have abnormal neurophysiologic condition, among whom four identifiable patterns of abnormality emerged. Five women (17%) had evidence of pudendal nerve demylenation with a prolonged sensory threshold of the clitoral-anal reflex (>5.2 mA), although electromyography studies were normal. Eight women (27%) had abnormal electromyography results that were consistent with axonal neuropathy with or without reinervation, in whom the clitoral-anal reflex was normal. Thirteen women (43%) demonstrated a mixed demyelinating and axonal pudendal neuropathy, with evidence of reinervation. Four women (13%) had abnormal patterns of neurophysiologic condition that was not attributable directly to past obstetric trauma but to coincident medical problems. CONCLUSION Four abnormal patterns of pudendal nerve function may be identified, three of which (demyelinating, axonal, and mixed demyelinating/axonal) can be attributed to specific past obstetric events, although a fourth radicular pattern is due to coincident medical or orthopedic problems. Assessment of pudendal nerve function is important in women with postpartum fecal incontinence because particular patterns of abnormality correlate with different symptoms and can influence treatment options.

The dual influences of age and obstetric history on fecal continence in parous women

To assess whether women who underwent forceps delivery were more likely than those who delivered either normally (spontaneous vaginal delivery [SVD]) or by cesarean to experience deterioration in fecal continence as they aged.

Evaluation of obstetric anal sphincter injury

Abstract Faecal incontinence presents with a female to male preponderance of 8:1 consistent with vaginal delivery as the principal causative factor. It results in serious social and psychological morbidity. Anal sphincter dysfunction following vaginal delivery generally results from direct muscular damage to the anal sphincter and/or cumulative damage to the pudendal nerves. Increasing attention is being focused on this relatively common and significant form of puerperal morbidity. Women with symtoms of faecal incontinence postpartum or a documented history of third degree tearshould be assessed where possible, in a multidisciplinary perineal clinic. Specific questioning concerning faecal incontinence is important because such symptoms are rarely volunteered. A detailed obstetric and medical history is essential. Application of a detailed bowel function questionnaire is helpful in establishing a ‘continence score’ which permits easy interpretation and comparison of disability. It also facilitates a comparative analysis of symptoms following treatment. Clinical signs suggestive of sphincter injury include perianal soiling, absence of the cutaneous anal reflex,patulous anus and local scarring but further physiological assessment is required to delineate the precise nature and prognosis of sphincter injury. This evaluation should include: endoanal ultrasound, which examines the anatomical integrity of the sphincter and anal mamometry, which assesses sphincter tone and contractile function. Pudental nerve function is tested using a combination of tests including electromyography (EMG) studies of anal sphincter muscle, pudendal nerve terminal motor latency and the clitoral anal reflex.