Abstract
Postpartum anal incontinence is common. After a first delivery (D1) with perineal trauma, follow-up is advised to reduce the risk of anal incontinence. Endoanal sonography (EAS) may be considered to evaluate the sphincter and in case of sphincter lesions to discuss cesarean section for the second delivery (D2). Our objective was to study the risk factors for anal continence impairment following D2. Women with a history of traumatic D1 were followed before and 6 months after D2. Continence was measured using the Vaizey score. An increase ≥2 points after D2 defined a significant deterioration. A total of 312 women were followed and 67 (21%) had worse anal continence after D2. The main risk factors for this deterioration were the presence of urinary incontinence and the combined use of instruments and episiotomy during D2 (OR 5.12, 95% CI 1.22–21.5). After D1, 192 women (61.5%) had a sphincter rupture revealed by EAS, whereas it was diagnosed clinically in only 48 (15.7%). However, neither clinically undiagnosed ruptures nor severe ruptures were associated with an increased risk of continence deterioration after D2, and cesarean section did not protect against it. One woman out of five in this population had anal continence impairment after D2. The main risk factor was instrumental delivery. Caesarean section was not protective. Although EAS enabled the diagnosis of clinically-missed sphincter ruptures, these were not associated with continence impairment. Anal incontinence should be systematically screened in patients presenting urinary incontinence after D2 as they are frequently associated.
1. Introduction
Anal incontinence (AI) is a taboo condition and a frequent cause of handicap, present in up to 20% of the population [1,2]. Its detection requires a dedicated investigation and can be difficult [3]. Continence is a complex mechanism involving the anal sphincter, rectal compliance, anorectal angulation, pudendal nerve innervation and the nature of the stools. Incontinence occurs when one or more of these mechanisms is altered beyond compensation [4]. Aging leads to a decrease in muscle and perineal trophicity and is one of the main risk factors for AI [5]. Various events in perineal life will accelerate this aging. Childbirth is one of these disruptors of pelvic integrity. The damage it causes to the perineum (mostly anal sphincter injury and pudendal nerve stretching) is frequent, affecting 12 to 28% of parturients [6,7] and can lead to AI in 4 to 40% of women giving birth [6,7,8,9,10]. Repeated deliveries lead to a risk of cumulative damages [7,11,12,13] and obstetrical life events contribute to a higher risk of AI in women compared to men [5,14,15].
Assessment of obstetrical anal sphincter injuries (OASI) is carried out immediately after delivery by the obstetrician/gynecologist, who describes any extension of a perineal tear to the anal sphincter. However, ruptures identified during an endoanal sonography (EAS) are undiagnosed at delivery in up to 30% of cases, and may be at risk of AI [6,9]. The extension of the sphincter damage is also estimated by EAS. Despite its potential advantages, the benefits of performing this procedure are debated because the diagnosis of a sphincter tear in EAS (EAS rupture) will not always have an impact on patient care (8).
Many studies in the literature focus on AI in primiparous women, but few address the risk factors of AI after a second delivery (D2), despite the fact that the fertility rate in France is close to two and that second child deliveries approach 250,000 annually [16,17]. An even smaller proportion of these studies have been conducted prospectively and none on large cohorts [18,19,20,21]. Moreover, there is a need to further investigate the risk factors of AI after D2 among women who have become vulnerable after a first traumatic delivery (D1), since a proctologist (surgeon or gastroenterologist) is then more likely to be consulted to advise about the risks and modalities of a new delivery.
The objective of our study was to determine the risk factors of continence impairment after D2 among women who had a traumatic D1, in particular the impact of EAS ruptures.
2. Materials and Methods
2.1. Population
Our work is an ancillary study of the prospective, randomized, multicenter “Prevention of Anal Incontinence by Caesarean Section” (EPIC) study, which compared the benefit of prophylactic caesarean section (CS) to vaginal delivery (VD) at D2 in women with a history of a traumatic D1 with sphincter rupture confirmed by EAS [8]. Women were recruited in six maternity units in the Paris area between April 2008 and December 2014. They were included by their gynecologist during the 3rd trimester of their 2nd pregnancy if they met the inclusion criteria, which were as follows: a single history of traumatic vaginal delivery (VD), defined as forceps extraction or with grade III perineal tear (reaching the sphincters), age above 18 years old, informed written consent and no AI at inclusion, based on a YES/NO answer to the question asked by the gynecologist. They were excluded if they had a history of grade IV perineum tear (which corresponds to the most severe grade of OASI with sphincter and anal mucosa damage) and if a CS was indicated for their future delivery for a non-proctological reason. After inclusion, systematic prospective follow-up was carried out, with a proctological examination during the 3rd trimester of their 2nd pregnancy (referred to as before D2 visit) and then 6 months after the second delivery (referred to as after D2 visit). This visit included questionnaires measuring the Vaizey score for anal continence and the measure of urinary handicap score (MHU) for urinary continence, as well as an EAS.
In the EPIC study, women with EAS sphincter rupture were randomized to perform D2 by VD or CS. Some women included in EPIC were not randomized, either because EAS did not reveal a sphincter rupture or because they refused randomization. The mode of delivery was then discussed between the obstetrician and the patient. In this study, we included all women who were explored by EAS before D2 and for whom a Vaizey score was calculated before and after D2, regardless of their randomization status.
2.2. Objective and Thresholds
The analysis of anal continence was based on the Vaizey score [22] (Appendix A). Data differs in the literature to assess which Vaizey value significantly defines incontinence [23]. In the EPIC study, based on this literature and on expert opinion, a score ≥5 defined AI [8,24]. Our population being inhomogeneous regarding continence before D2, we selected as the primary endpoint worsening of the Vaizey score after D2, defined as an increase ≥2 points in the score between the two proctological examinations. Comparable definitions were used in previous proctologic studies [25].
Because transient AI (lasting less than 2 months) is common in the immediate postpartum period [26,27], the assessment 6 months after D2 was used to measure persistent continence deterioration.
EAS was performed by a single trained operator, using a rotating rectal probe (7–10 MHz, Brüel and Kjaer). Upper, middle and lower anal canal were studied. A sphincter lesion was identified as a loss of continuity visible by a change in echogenicity within the sphincter ring [28]. Severity was assessed based on the Starck score (Appendix B). A score ≥9 was used to define a severe sphincter rupture [29,30]. The clinical description of perineal lesions was based on the Royal College of Obstetricians and Gynecologists classification, where the anal sphincter is considered impaired in grades III and IV (Appendix C). We defined a “hidden sphincter rupture” as a tear undiagnosed in the delivery room (or under-diagnosed as a grade I or II) but observed by EAS. After D2, ruptures were considered “de novo” if no EAS defect was visible after D1.
The analysis of urinary continence was based on the MHU score (Appendix D) [31], treated as a continuous variable ranging from 0 to 28 points. Macrosomia was defined by birthweight >4 kg [32]. Birthweight was not collected in D2 in the case of CS. Instrumental delivery referred to the use of all types of forceps or vacuum but the type of forceps was not specified. Details of the episiotomy were not collected. We defined “abnormal transit” as the presence of diarrhea, constipation or dyschesia. We asked the patients whether or not they had undergone perineal rehabilitation, but the modalities were not collected (number of sessions or technique used).
2.3. Statistical Analysis
Categorical variables were described as numbers and percentages and quantitative variables were described as median and interquartile ranges. We compared median Vaizey scores at the two visits with Wilcoxon paired tests. To assess the association between the primary outcome and the characteristics of the women, univariate logistic regressions were performed to determine unadjusted odds ratios (OR) and their 95% confidence intervals. Variables with a univariate p value < 0.20 were tested in multivariate models. Variable selection for the final multivariate model was performed using top-down selection with the Akaike information criterion. The linearity assumption was tested graphically and with the Wald test for the MHU score. An analysis on the subgroup of women giving birth by VD at D2 was conducted using the same methodology, to study the impact of a second vaginal delivery and its characteristics. p values < 0.05 were considered significant. The tests were two-sided. All analyses were performed using R software (v.3.4).
3. Results
3.1. Participants
A total of 549 parturients were included in the EPIC study, of which 312 had a Vaizey score completed before and after D2 and were included in our ancillary work (Figure 1). Characteristics of the population are described in Table 1.
Figure 1.
Flow Chart.
Table 1.
Characteristics of the population.
3.2. Characteristics of the Deliveries
3.2.1. First Delivery (D1)
Among the 312 women included, 285 (92.2%) delivered with forceps at D1 and 266 (86.9%) had episiotomies. After D1, there were 27 (8.9%) grade I, 15 (4.9%) grade II and 48 (15.7%) grade III perineal tears. An OASI was therefore only clinically visible in these 48 women. However, the EAS performed before D2 showed sphincter tears in 192 (61.5%) of these women. After D1, 225 (74.3%) women had perineal rehabilitation.
3.2.2. Second Delivery (D2)
A total of 103 women (34.8%) delivered by CS and 193 (65.2%) by VD. For 16 women (5.1%), the mode of delivery was not recorded. Among the 193 VD, there were 13 forceps (6.7%), 12 vacuum (6.2%), 49 episiotomies (25.4%) and 87 grade I (45.1%), 24 grade II (12.4%) and 2 grade III (1.0%) perineal tears. After D2, 201 (64.4%) women underwent perineal rehabilitation. Characteristics of the second delivery among the subgroup of women delivering vaginally is described in Table 2.
Table 2.
Characteristics of the subgroup of women delivering vaginally during D2.
3.3. Characteristics of Continence
Before D2, 43 (13.8%) women had a Vaizey score ≥ 5 and the median Vaizey score was 1 [0–3]. After D2, the median Vaizey score remained unchanged across the total population, with no significant worsening (p = 0.33). However, 67 women (21.5%) significantly worsened their continence score (≥2 points) and increased their median Vaizey score from 1 [0–2] before D2 to 5 [3–7] afterwards. The median MHU score was 4/28 [2–8] during the 3rd trimester of the 2nd pregnancy and 1/28 [0–4] 6 months after D2. Details of the outcomes measured 6 months after D2 are presented in Table 3.
Table 3.
Outcomes measured 6 months after D2.
3.4. Risk Factors for Deterioration of Anal Continence 6 Months after D2
3.4.1. Among the 312 Included Patients
Maternal weight, ethnicity, fetal presentation, macrosomia at D1, transient AI after D1, lack of perineal rehabilitation and the presence of a sphincter rupture diagnosed in EAS before D2 (whether occult or not and whether the EAS rupture was severe or not), were not associated with an increased Vaizey score after D2 (Table 4) in univariate analysis.
Table 4.
Factors associated with a worsening of the Vaizey score ≥ 2 points after second delivery (Univariate analysis).
In multivariate analysis, delivering by CS did not impact significantly the risk of worsening continence after D2 compared to VD (Table 5). Women who were already incontinent before D2 were less likely to deteriorate in their Vaizey score after D2 (OR 0.27–95% CI 0.08–0.86). Increase in MHU score after D2 was linearly associated with a risk of continence deterioration (OR increased by 1.24 per MHU point-95% CI 1.08–1.42).
Table 5.
Factors associated with a worsening of the Vaizey score ≥ 2 points after second delivery (Multivariate analysis).
3.4.2. Among the 193 Patients That Delivered Vaginally at D2
In this subgroup, in univariate analysis, macrosomia, the absence of perineal rehabilitation after D1 or D2 and the presence of an endosonographic or clinical sphincter rupture were not associated with an increased Vaizey score after D2 (Table 6). Instrumental delivery, with or without episiotomy, increased the risk of worsening anal continence after D2. We did not find a significant association with episiotomy itself.
Table 6.
Factors associated with a worsening of the Vaizey score ≥ 2 points after second delivery in subgroup of women delivering vaginally (Univariate analysis).
In multivariate analysis (Table 7), instrumental delivery or episiotomy were associated with a deterioration of anal continence only when performed together (OR 4.18–95% CI 1.05–16.59). Increase in MHU score after D2 was linearly associated with a risk of AI (OR1.25 per MHU point-95% CI 1.11–1.43).
Table 7.
Factors associated with a worsening of the Vaizey score ≥ 2 points after the second delivery in the subgroup of women delivering vaginally (Multivariate analysis).
3.5. Sphincter Tears
3.5.1. Sphincter Tears before D2
192 (61.5%) women had an EAS sphincter rupture before D2, whereas only 48 (15.7%) had a grade III OASI clinically recognized by the obstetrician in the delivery room during D1. These hidden ruptures were not accompanied by an increased risk of continence impairment after D2 (Table 2). The description of sphincter ruptures is provided Appendix E.
3.5.2. Sphincter Tears after D2
A total of 143 (71.9%) women had sphincter ruptures revealed by the EAS performed after D2 (out of 199 who underwent EAS). Only six had “de novo” sphincter ruptures. These were women who had delivered vaginally, including one with episiotomy. The subgroup was too small to evidence a significant association between these ruptures and continence impairment in univariate analysis.
4. Discussion
4.1. Main Results
To our knowledge, this study is the largest prospective cohort describing risk factors for continence impairment after a second delivery in at-risk parturients. The main risk factor was instrumental extraction coupled with an episiotomy during a second vaginal delivery. These results are consistent with the literature and the absence of an increased risk related to episiotomy when analyzed independently is reassuring regarding the controversial impact of this procedure [7,24].
The risk factors of postpartum AI are still debated. Forceps delivery and perineal tears are frequently associated with AI [7,11,13,33]. But the association is less clear for episiotomy, multiparity [7,11], macrosomia and nulliparity [13]. In our work, none of these factors were associated with an increased risk of continence impairment after D2, possibly because we studied at D2 the impact of some events occurring at D1 and because we relied on a large and prospective cohort, unlike previous studies.
We found a strong association between the presence of urinary incontinence after D2 and the presence of AI. Patients and their physicians are often aware of the risk of urinary incontinence after delivery, while the diagnosis of AI is more challenging. The diagnosis of urinary incontinence could initiate dialogue between the obstetrician and the proctologist.
At inclusion, several women denied having AI during non-specific questioning, while a more focalized interview during the proctological consultation enabled a proper continence evaluation.
Surprisingly, the presence of AI before D2 was associated with a decreased risk of continence impairment after D2. We assume that some women had signs of AI related to the pregnancy itself, due to transit and pelvic static disorders, which improved after the delivery.
CS was not associated with a decreased risk of continence impairment after D2. This is consistent with the EPIC study [8] and recent literature [34,35].
4.2. The Place of EAS
Women with traumatic deliveries are routinely offered EAS examination in order to detect a clinically undiagnosed sphincter defect. We indeed observed that among half of the patients, an anal sphincter rupture had been missed clinically but was evidenced by EAS, which is consistent with the literature [6,9].
The EPIC study demonstrated however, that it was not beneficial to perform prophylactic cesarean section to these patients to prevent the occurrence of AI after D2 [8]. Our study goes further, showing that neither the presence of these hidden sphincter ruptures diagnosed before a second delivery, nor even the most severe sphincter tears, were associated with a significant risk of continence impairment after D2. We therefore have no argument for advocating the use of EAS after a first traumatic delivery. However, in our practice, performing an EAS, as frequently requested by maternities, allows these women at-risk to have access to a proctologist, who can inform them about long-term risk factors for AI and avoidable cofactors.
These results can be challenged by the relative scarcity of severe sphincter tears in our study, mostly because of the low percentage of internal sphincter injuries, which strongly impacts Starck’s score [29,30]. In Sultan’s cohort [9], 16% of women had an internal sphincter defect versus only 5.8% in our study. These results may be explained by the exclusion of patients with grade IV perineal tears or already reporting AI to their gynecologist after D1. There is therefore still room to debate the benefits of EAS among these patients.
4.3. Strengths and Limitations
We collected data in medical centers representative of the population pools of our region and we relied on validated clinical criteria (Vaizey score, MHU score) and paraclinical criteria (Starck’s score [29,30]). EAS were performed by a single expert operator, which limited ranking bias by preventing inter-operator variability. Moreover, the inter-operator concordance of this practitioner had already been validated in a previous work [7].
There is no consensus on thresholds defining AI in literature. We chose to define a continence impairment as an increase in two points of the Vaizey score after D2. This is a sensitive threshold for continence deterioration but not a very specific one.
Anal incontinence tends to decrease in the weeks following delivery and to reappear after menopause. One of the limitations of this work is the lack of follow-up beyond one year after D2.
Although the follow-up was prospective, we conducted this work after the legal closing date of the original study, which prevented us from completing the missing data. Therefore, 122/434 (28%) of women who underwent EAS before D2 were not analyzed. However, we did not evidence any difference between the baseline characteristics of our population and this unanalyzed population (Appendix F).
4.4. What Can Be Offered to a Woman at Risk of Continence Impairment after D2
Potential perineal damage risk can be reduced by measures such as regulating transit, treating dyschesia (source of pudendal stretch or prolapse) and avoiding additional sphincter trauma as much as possible. It is thus advisable to refer women at risk or presenting postpartum AI to proctologists for multi-disciplinary management.
Although the main risk factor for continence impairment is forceps delivery with episiotomy, these obstetrical interventions are sometimes necessary and cannot be completely avoided.
In case of proven AI and after managing possible cofactors, pelvic rehabilitation with biofeedback or neuromodulation of the sacral roots may be beneficial [36,37,38].
5. Conclusions
After a first traumatic delivery, instrumental delivery with episiotomy is the main risk factor for anal continence impairment during a second delivery. Women who present symptoms of urinary incontinence after their second delivery also are at greater risk of developing symptoms of anal incontinence. Referral to a proctologist will improve the detection and management of this incontinence. Caesarian section does not prevent it. In a woman wishing to start a second pregnancy after a first traumatic delivery, the presence of a sphincter lesion on endoanal ultrasound will not change the course of treatment.
Author Contributions
Conceptualization, G.M., A.D. and L.A.; methodology, G.M., A.D. and L.A.; investigation, A.B.-M., A.L.T., C.D.C.-C., O.P., G.G., A.B., L.M. and L.A.; writing—original draft preparation, G.M.; writing—review and editing, G.M., A.D., L.M., L.A. All authors have read and agreed to the published version of the manuscript.
Funding
This study is an ancillary study of the randomized EPIC study (Abramowitz et Al, BJOG, 2021) which was funded by the French Ministry of Health National Program for Clinical Research Grant (PHRC) (AOR number 06004).
Institutional Review Board Statement
This study is an ancillary study of the randomized EPIC study (Abramowitz et Al, BJOG, 2021) which was approved by the Comité de Protection des Personnes (Ethical Human Subjects Protection Review) Paris-Ile-de-France V of Saint Antoine Hospital PARIS 12 on the 02 October 2007 (n°07709) and French Health Authority on 22 October 2007 (Ref: DGS2007-0188).
Informed Consent Statement
This study is an ancillary study of the randomized EPIC study (Abramowitz et Al, BJOG, 2021) where informed consent was obtained from all subjects involved.
Data Availability Statement
All data are available on request to the corresponding author.
Conflicts of Interest
The authors declare no conflict of interest.
Abbreviations
| AI | Anal incontinence |
| OASI | Obstetrical anal sphincter injury |
| EAS | Endoanal sonography |
| EAS rupture | Sphincter tear diagnosed in EAS |
| D1 | First delivery |
| D2 | Second delivery |
| VD | Vaginal delivery |
| CS | Caesarian section |
| EPIC | Prevention of anal incontinence by Caesarean section |
| MHU | Measure of urinary handicap |
| BMI | Body mass index |
| OR | Odds ratio |
Appendix A. Vaizey Score
| Never | Rarely | Sometimes | Weekly | Daily | |
| Solid stools incontinence | 0 | 1 | 2 | 3 | 4 |
| Liquid stools incontinence | 0 | 1 | 2 | 3 | 4 |
| Flatus incontinence | 0 | 1 | 2 | 3 | 4 |
| Quality of life impairment | 0 | 1 | 2 | 3 | 4 |
| No | Yes | ||||
| Need to wear diapers | 0 | 2 | |||
| Use of a constipating treatment | 0 | 2 | |||
| Impossible to delay defecation for more than 15 min | 0 | 4 | |||
| Never: no episode in the last 4 weeks. Rarely: one episode in the last 4 weeks. Sometimes: one or more episode in the last 4 weeks but less than one episode per week. Weekly: one or more episode per week. Daily: one or more episode per day. Vaizey, C.J.; Carapeti, E.; Cahill, J.A.; Kamm, M.A. Prospective comparison of faecal incontinence grading systems. Gut 1999, 44, 77–80. | |||||
Appendix B. Starck’s Score
| Defect Characteristics | Score | |||
| 0 | 1 | 2 | 3 | |
| External sphincter | ||||
| Length of defect | None | Half or less | More than half | Whole |
| Depth of defect | None | Partial | Total | - |
| Size of defect | None | ≤90° | 91–180° | ≥180° |
| Internal sphincter | ||||
| Length of defect | None | Half or less | More than half | Whole |
| Depth of defect | None | Partial | Total | - |
| Size of defect | None | ≤90° | 91–180° | ≥180° |
| No defect = Score 0/Maximal defect = Score 16 | ||||
| Starck, M.; Bohe, M.; Valentin, L. Results of endosonographic imaging of the anal sphincter 2–7 days after primary repair of third- or fourth-degree obstetric sphincter tears. Ultrasound Obs. Gynecol 2003, 22, 609–615. | ||||
Appendix C. Perineal Tears: Classifications of the Royal College of Obstetricians and Gynecologists (RCOG) and World Health Organization (WHO)
| RCOG and WHO Grades | Anatomical Lesions |
| I | Vaginal epithelium tear |
| II | Tear of the perineal muscles |
| III | Sphincter impairment |
| III-A |
|
| III-B |
|
| III-C |
|
| IV | Breach of the rectal mucosa |
Appendix D. Urinary Handicap Measurement Score (MHU)
| Score | 0 | 1 | 2 | 3 | 4 |
| Urinary urgency | None | Safety time between 10 and 15 min | Safety time between 5 and 10 min | Safety time between 2 and 5 min | Safety time < 2 min |
| Urinary leakage due to urgency | None | Less than once a month | Several times a month | Several times a week | Several times a day |
| Daytime urination frequency | Urinary interval > 2 h | Voiding interval 1.5 to 2 h | Voiding interval 1 h | Voiding interval half an hour | Voiding interval < half an hour |
| Nocturnal urinary frequency | 0 or 1 miction/night | 2 mictions/night | 3–4 mictions/night | 5–6 mictions/night | >6 mictions/night |
| Stress urinary incontinence | None | During violent efforts (sport, running) | During mild efforts (cough, sneeze, laugh) | During light efforts | Even during change of position |
| Other incontinence | None | Postmictional leaks (>1/month) | Postmictional leaks (1/week) | Postmictional leaks (>1/week) | Postmictional leaks (1/day) |
| Dysuria or Retention | None | Waiting dysuria, terminal dysuria | Abdominal thrusts, chopped miction | Manual thrusts, prolonged urination, residual sensation | Need for a urinary probe |
| Marquis, P.; Amarenco, G.; Sapede, C.; Josserand, F.; McCarthy, C.; Zerbib, M., et al. Elaboration and validation of a specific quality of life questionnaire for urination urgency in women. Prog Urol. 1997, 7, 56–63. | |||||
Appendix E. Description of Sphincter Lesions Revealed in EAS after the First and Second Delivery
| Sphincter Defects before D2 | Total (N = 312) |
| Sphincter tear | 192 (61.5%) |
| Puborectal tear | 0 (0%) |
| Internal sphincter tear (IS) | 18 (5.8%) |
| 0 (0%) |
| 2 (0.6%) |
| 13 (4.2%) |
| 5 (1.6%) |
| Full thickness external sphincter (ES) tear | 103 (33%) |
| Profound ES layer | 175 (56.1%) |
| 5 (1.6%) |
| 123 (39.4%) |
| 166 (53.2%) |
| Superficial ES layer | 120 (38.5%) |
| 2 (0.6%) |
| 110 (35.3%) |
| 116 (37.2%) |
| Sphincter ruptures after D2 | Total (N = 199) |
| Sphincter tear | 143 (71.9%) |
| Puborectal tear | 0 (0%) |
| Internal sphincter tear (IS) | 11 (5.5%) |
| Full thickness external sphincter (ES) rupture | 71 (33.5) |
| Profound ES layer teared | 125 (62.8%) |
| Superficial ES layer teared | 90 (45.2%) |
| “De novo” sphincter rupture | 6 (2.2%) |
| Sphincter defect evidenced in EAS after both deliveries | 133 (66.8%) |
| D2: Second delivery. IS: Internal sphincter. ES: External sphincter. | |
Appendix F. Comparison of the Characteristics of Our Population with those of Women Eligible but Excluded from the Analysis
| Total (N = 312) | NA | Excluded Patients (N = 122) | NA | p | |
| Median age [IQR]. | 33.4 [30.3–35.8] | 0 | 31.1 [27.7–34.2] | 0 | 0.001 |
| Median BMI [IQR] | 26.17 [23.9–29] | 5 | 26.4 [24.4–29.0] | 7 | 0.7 |
| Patients with BMI > 30 | 64 (20.8%) | 5 | 23 (20%) | 7 | 0.6 |
| Transit | |||||
| Constipation and/or Dyschesia | 78 (25%) | 8 | 22 (19%) | 7 | 0.2 |
| Diarrhea | 8 (2.6%) | 8 | 0 (0%) | 7 | 0.1 |
| Normal transit | 211 (69.4%) | 8 | 82 (71%) | 7 | 0.8 |
| Geographical origin | 5 | 3 | |||
| Asia | 12 (3.9%) | 5 (4.2%) | 0.001 | ||
| Europe | 202 (65.8%) | 50 (42%) | |||
| Maghreb | 57 (18.6%) | 42 (35%) | |||
| Other | 36 (11.7%) | 22 (18%) | |||
| Characteristics of D1 | |||||
| Median gestational age in weeks [IQR] | 40 [39–41] | 5 | 40 [39–41] | 5 | 0.3 |
| Use of forceps | 285 (92.2%) | 3 | 106 (90%) | 4 | 0.5 |
| Episiotomy | 266 (86.9%) | 6 | 98 (85%) | 7 | 0.8 |
| Macrosomia | 18 (5.8%) | 4 | 11 (9.3%) | 4 | 0.3 |
| Perineal rehabilitation performed | 225 (74.3%) | 9 | 67 (60%) | 10 | 0.006 |
| Perineal tear | 95 (30.7%) | 7 | 45 (38%) | 8 | 0.6 |
| 27 (8.9%) | 11 (26%) | |||
| 15 (4.9%) | 7 (17%) | |||
| 48 (15.7%) | 22 (52%) | |||
| EAS rupture after D1 | 192 (61.5%) | 0 | 72 (59%) | 0 | 0.3 |
| Hidden rupture after D1 | 146 (47.9%) | 7 | 45 (39%) | 8 | |
| Severe rupture after D1 (Starck ≥ 9) | 18 (5.8%) | 0 | 4 (3.3%) | 0 | 0.5 |
| Continence before D2 | |||||
| Transient anal incontinence | 48 (15.7%) | 7 | 11 (9.5%) | 6 | 0.13 |
| Median Vaizey score before D2 [IQR] | 1 [0–3] | 0 | 0 [0–6] | 4 | 0.9 |
| Median MHU score [IQR] | 4 [2–8] | 16 | 4 [1–8] | 8 | 0.6 |
| Anal incontinence (Vaizey ≥ 5) before D2 | 43 (13.8%) | 0 | 12 (10%) | 4 | 0.4 |
| IQR: Interquartile range. BMI: Body mass index. EAS rupture: Sphincter tear diagnosed in endoanal sonography. NA: Missing data for each characteristic in our main population. p: Significance of the difference in distribution of the variable between the included and excluded population. D1: 1st delivery-D2: 2nd delivery. | |||||
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