Australian and New Zealand Journal of Obstetrics and Gynaecology 2014; 54: 371–376
DOI: 10.1111/ajo.12222
Original Article
Perineal outcome and the risk of pelvic floor dysfunction: A cohort study of primiparous women Joan RIKARD-BELL,1 Jay IYER1,2 and Ajay RANE1,2 1
Department of Obstetrics and Gynaecology, James Cook University, Townsville, Queensland, Australia, and 2The Townsville Hospital, Townsville, Queensland, Australia
Background: Pelvic floor dysfunction (PFD) is the most common complication of childbirth. Assumptions have been made that perineal trauma increases the risk of PFD compared to an intact perineum, however the evidence for this is lacking. The aim of this study was to explore the relationship between perineal outcome and postpartum PFD. Materials and Methods: Prospective cohort study design, with a self-reported quality of life (QOL) questionnaire mailed to all primiparous women with a non-instrumental delivery at The Townsville Hospital between 2011 and 2012 (n = 766). ANOVA was used to compare how the symptoms of PFD affect QOL in women with an intact perineum, episiotomy or spontaneous tear. Results: Seventy-nine percent of the population had perineal injury; 60% had a spontaneous tear and 19% had an episiotomy. Ninety-seven percent of women who completed the questionnaire (n = 196) complained of PFD symptoms. Women with episiotomy had the best QOL, reporting the lowest levels of urinary dysfunction (statistically significant). No differences between the groups were found for symptoms of bowel, prolapse or sexual dysfunction. Conclusions: This study shows a relationship between perineal outcome and PFD and suggests that an episiotomy is associated with the least morbidity due to symptoms of urinary incontinence. Additional large-scale prospective research is required to further investigate and delineate the impact of childbirth on PFD. Key words: perineum, episiotomy, pelvic floor, incontinence, quality of life.
Introduction Perineal trauma affects approximately 85% of Australian women following vaginal delivery.1 Assumptions have been made that women with perineal trauma are at an increased risk of pelvic floor dysfunction (PFD) compared to those with an intact perineum. PFD is the most common complication after childbirth, affecting up to 94% of women.2 The exact damage caused by vaginal delivery on the pelvic floor is still largely unknown, hence the need to study perineal outcome and the risk of developing PFD. There is a lack of consensus over the proposed benefits of episiotomy; this is reflected in variations in rates of use. Episiotomy rates range from as low as 9% in Sweden to close to 100% in Taiwan;3 the average rate in Australia is currently 13%.1 This arises from the different emphasis placed on the importance of an intact perineum. Currently an intact perineum is considered an indicator of good
Correspondence: Dr Joan Rikard-Bell, Blacktown Hospital, Blacktown Road, Blacktown, NSW 2148, Australia. Email: [email protected] Received 29 October 2013; accepted 26 April 2014.
obstetric care however the evidence for this is lacking. Our aim was to explore the relationship between perineal outcome and postpartum PFD, and examine the influence of PFD on quality of life (QOL).
Materials and Methods We performed a prospective cohort study at The Townsville Hospital, a 420-bed tertiary hospital that performs 2400 deliveries per annum. For inclusion participants had to be primiparous with a non-instrumental delivery from 1 January 2011 to 31 December 2012. Exclusion criteria were women whose baby died during labour or in the peripartum period. Women were identified using the hospital’s obstetric database Matrix; this database is updated and maintained during and after pregnancy and contributes to statewide data collection. The Townsville Hospital moved from paper to electronic records late in 2010 and thus the sample size was chosen empirically, using collated and validated data available in Matrix. Participants were divided into three groups based on their perineal outcome as reported in Matrix: intact perineum; episiotomy; and spontaneous tear.
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
371
J. Rikard-Bell et al.
Participants were mailed a self-reported QOL questionnaire at least six months after childbirth which consisted of short forms of the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). The questionnaire was administered to all groups twice, 14 weeks apart to increase the response rate; women were requested not to return a completed questionnaire twice. ANOVA was performed to compare the three groups of perineal trauma and the impact of PFD on their QOL. The post hoc Games–Howell test was performed where ANOVA was significant; significance was accepted at the 5% level. Outliers were excluded from analysis to gain more reliable results using ANOVA; outliers were identified using descriptive statistics, the data were inspected to ensure no errors and the individual data points removed. This study was approved by the Townsville Hospital Health Service Human Research Ethics Committee and Research Governance Office. This study also received approval for access and use of specified confidential information under the Public Health Act 2005.
Results Of the 766 women recruited, 79% had perineal injury, 60% had a spontaneous tear and 19% had an episiotomy (Table 1). Five per cent sustained severe perineal trauma (a third- or fourth-degree tear). Table 2 illustrates the clinical characteristics of the three groups; birthweight and stage two duration were greatest where perineal trauma occurred. 196 women returned a completed questionnaire; 97% of these women complained of symptoms of PFD.
Urinary symptoms Eighty-two per cent of women reported urinary symptoms causing bother. Sixty-three percent experienced urinary incontinence (UI); 50% had urine leakage related to coughing, sneezing or laughing, whilst 39% complained of small amounts of urine leakage. Women with an intact perineum reported the highest rate of UI (71%), followed by a spontaneous tear (66%) and then an episiotomy (60%). Overall, women who had an episiotomy reported Table 1 Perineal outcomes for primiparous women with a noninstrumental vaginal delivery (n = 766) Perineal outcome
n
%
Intact perineum Spontaneous tears 1st degree 2nd degree 3rd degree 4th degree Episiotomy Mediolateral Lateral Midline
163 458 156 280 18 4 145 136 5 4
21 60 20 37 2 1 19 18 0.5 0.5
372
the least amount of bother from urinary symptoms, whilst those with a spontaneous tear were most distressed (Table 3); ANOVA (Table 4) and post hoc Games– Howell test (Table 5) indicate that the mean urinary distress (UDI-6) score for women with an episiotomy is significantly lower than that of intact perineum and spontaneous tear (F2,194 = 7.69, P = 0.01).
Colorectal anal symptoms Seventy-nine per cent of women experienced bowel symptoms causing bother. Thirty-nine percent complained of anal incontinence (AI); 34% were incontinent of gas, 18% were incontinent of loose stool and 10% incontinent of solid stool. Women with an intact perineum reported the highest rate of AI (44%), followed by a spontaneous tear (37%) and then an episiotomy (35%); similar rates of incontinence of gas were found in all perineal outcomes, however the involuntary loss of loose and well-formed stool for women with an episiotomy was almost half that of women with other perineal outcomes. However, this study was unable to demonstrate a difference between the groups for overall bother caused by bowel symptoms (F2,194 = 1.13, P = 0.33) (Tables 3 and 4).
Pelvic organ prolapse Nine per cent of women complained of symptoms of pelvic organ prolapse (POP) impacting on their QOL, defined by a bulge seen or felt in the vaginal area. Women with an intact perineum reported the lowest rate of POP symptoms causing bother (6%), followed by an episiotomy (9%) and a spontaneous tear (13%). An association between perineal trauma and bother caused by POP was unable to be confirmed in this study (F2,194 = 0.19, P = 0.82) (Tables 3 and 4).
Sexual dysfunction Ninety-eight percent of women complained of sexual dysfunction. The most frequent symptoms were dyspareunia (70%) and negative emotional reactions to sexual intercourse (56%). Thirty-three per cent avoided sexual intercourse because of UI and 10% because of POP. Twenty-two percent were always satisfied with the variety of sexual activities, 24% felt sexually excited during intercourse and 16% climaxed when having intercourse with their partner, for 31% this was less intense than the previous six months. No association between perineal trauma and the impact of sexual dysfunction on QOL was demonstrated in this study (F2,194 = 0.45, P = 0.64) (Tables 3 and 4).
Discussion Perineal trauma is the most common complication associated with vaginal delivery. Compared to Queensland statistics, our rates of perineal trauma were slightly higher
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Perineal outcome and the pelvic floor Table 2 Maternal and fetal characteristics of the sample population (n = 766) Intact perineum
Oxytocin stimulation Yes No Epidural anaesthesia Yes No Maternal birthing position Upright Recumbent Other/Unknown Accoucheur Midwife Obstetrician or Obstetrics Registrar Student midwife Registered Medical Officer or Medical student Maternal age (years)† Gestational age (weeks)† Maternal weight (kg)†,‡ Fetal birthweight (g)† Stage two duration (min)†
Episiotomy
Spontaneous tear
n = 163
%
n = 145
%
n = 458
%
42 121
26 74
54 91
54 56
153 305
33 67
3 160
2 98
10 135
7 93
26 432
6 94
25 135 3
15 83 3
2 141 2
1 98 1
47 394 17
10 86 4
84 51 14 9 59 36 6 4 23.4 (16–41) 39 (26–42) 70.0 (40–148) 3058 (915–4580) 39.9 (0–171)
77 53 29 20 33 23 4 4 24.8 (16–38) 40 (30–42) 71.1 (40–130) 3410 (1551–4360) 65.5 (0–247)
262 57 14 3 155 34 27 6 24.4(15–40) 39 (29–42) 74.1 (39–150) 3381 (1418–4730) 47.6 (0–256)
†Median (range). ‡Note 17 women had missing data for maternal weight.
Table 3 Means and standard deviations comparing groups of perineal outcome on quality of life (QOL) scales n
Mean
SD
Urinary Distress Inventory – 6 (UDI-6) Intact perineum 60 40.56 14.37 Episiotomy 41 32.11 6.54 Spontaneous tear 86 36.25 9.26 Colorectal Anal Distress Inventory – 8 (CRADI-8) Intact perineum 59 35.91 10.72 Episiotomy 43 33.21 6.99 Spontaneous tear 86 35.66 10.38 Pelvic Organ Prolapse Distress Inventory – 6 (POPDI-6) Intact perineum 53 29.95 4.91 Episiotomy 45 29.76 4.78 Spontaneous tear 85 30.39 6.89 Pelvic Floor Distress Inventory – 20 (PFDI-20) Intact perineum 59 60.57 57.15 Episiotomy 46 56.13 48.56 Spontaneous tear 89 55.71 51.97 Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire – 12 (PISQ-12) Intact perineum 57 7.44 3.64 Episiotomy 41 8.08 3.43 Spontaneous tear 90 8.07 4.79
(79 vs 70%); whilst spontaneous tears occurred slightly more frequently in our women (60 vs 59%), episiotomy was performed more often (19 vs 11%).1
Pelvic floor dysfunction is very common in the immediate postpartum period; it tends to remit by six months2 although in a considerable number of cases it does persist and the management of vaginal delivery appears to offer an opportunity to reduce its morbidity.4 Amongst our population, PFD was present after the sixth month postpartum in 98% of women. Urinary symptoms causing bother were reported by 82% of our women. UI, reported by 63% of women, was the most common complaint; 50% reported some degree of stress urinary incontinence (SUI) and 41% a degree of urge urinary incontinence (UUI). This compares well with rates reported in the literature.5,6 Women with an episiotomy reported the lowest rate of UI while those with an intact perineum reported the highest rate. UI is thought to result from loss of support and suspension provided by pelvic fascia, connective tissue and pelvic floor muscles; indirect damage to the nerves of the pelvic floor and bladder may also be implicated.4 Vaginal delivery was confirmed as a key risk factor for SUI in two identical twin sister studies.7,8 Episiotomy widens the vaginal opening for delivery of the fetus, reducing the distortion of pelvic floor tissues required for vaginal delivery. It therefore seems plausible that failure to perform an episiotomy is a risk factor for pelvic relaxation and subsequent development of UI. Furthermore, anterior perineal trauma occurs less often where an episiotomy is performed, suggesting that it may protect against trauma in this region.3 In this study, the lowest rate of UI was seen in women who had an
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
373
J. Rikard-Bell et al.
Table 4 ANOVA summary table comparing groups of perineal outcome on quality of life (QOL) scores df
SS
MS
Urinary Distress Inventory – 6 score Between groups 2 1772 886 Within groups 191 21176 115 Total 193 22949 Colorectal Anal Distress Inventory – 8 score Between groups 2 218 109 Within groups 191 17886 97 Total 193 18104 Pelvic Organ Prolapse Distress Inventory – 6 score Between groups 2 114 7 Within groups 191 6246 35 Total 193 6260 Pelvic Floor Distress Inventory – 20 score Between groups 2 918 459 Within groups 191 533269 2792 Total 193 534188 Pelvic Organ Prolapse/Urinary Incontinence Sexual – 12 score Between groups 2 16 8 Within groups 191 3255 18 Total 193 3271
F
P
7.69
0.01
1.13
0.33
0.19
0.82
0.16
0.85
Questionnaire 0.45
0.64
df, degrees of freedom; SS, sums of squares; MS, mean of squares; F, between group differences; P, probability.
Table 5 Games–Howell test comparing groups of perineal outcome on UDI-6 scores Mean difference
UDI-6 score Intact perineum Episiotomy Spontaneous tear
Episiotomy Spontaneous tear Intact perineum Spontaneous tear Intact perineum Episiotomy
8.44 4.30 8.44 4.14 4.30 4.14
SE
P
2.12 2.11 2.12 1.43 2.12 1.43
DOI: 10.1111/ajo.12222
Original Article
Perineal outcome and the risk of pelvic floor dysfunction: A cohort study of primiparous women Joan RIKARD-BELL,1 Jay IYER1,2 and Ajay RANE1,2 1
Department of Obstetrics and Gynaecology, James Cook University, Townsville, Queensland, Australia, and 2The Townsville Hospital, Townsville, Queensland, Australia
Background: Pelvic floor dysfunction (PFD) is the most common complication of childbirth. Assumptions have been made that perineal trauma increases the risk of PFD compared to an intact perineum, however the evidence for this is lacking. The aim of this study was to explore the relationship between perineal outcome and postpartum PFD. Materials and Methods: Prospective cohort study design, with a self-reported quality of life (QOL) questionnaire mailed to all primiparous women with a non-instrumental delivery at The Townsville Hospital between 2011 and 2012 (n = 766). ANOVA was used to compare how the symptoms of PFD affect QOL in women with an intact perineum, episiotomy or spontaneous tear. Results: Seventy-nine percent of the population had perineal injury; 60% had a spontaneous tear and 19% had an episiotomy. Ninety-seven percent of women who completed the questionnaire (n = 196) complained of PFD symptoms. Women with episiotomy had the best QOL, reporting the lowest levels of urinary dysfunction (statistically significant). No differences between the groups were found for symptoms of bowel, prolapse or sexual dysfunction. Conclusions: This study shows a relationship between perineal outcome and PFD and suggests that an episiotomy is associated with the least morbidity due to symptoms of urinary incontinence. Additional large-scale prospective research is required to further investigate and delineate the impact of childbirth on PFD. Key words: perineum, episiotomy, pelvic floor, incontinence, quality of life.
Introduction Perineal trauma affects approximately 85% of Australian women following vaginal delivery.1 Assumptions have been made that women with perineal trauma are at an increased risk of pelvic floor dysfunction (PFD) compared to those with an intact perineum. PFD is the most common complication after childbirth, affecting up to 94% of women.2 The exact damage caused by vaginal delivery on the pelvic floor is still largely unknown, hence the need to study perineal outcome and the risk of developing PFD. There is a lack of consensus over the proposed benefits of episiotomy; this is reflected in variations in rates of use. Episiotomy rates range from as low as 9% in Sweden to close to 100% in Taiwan;3 the average rate in Australia is currently 13%.1 This arises from the different emphasis placed on the importance of an intact perineum. Currently an intact perineum is considered an indicator of good
Correspondence: Dr Joan Rikard-Bell, Blacktown Hospital, Blacktown Road, Blacktown, NSW 2148, Australia. Email: [email protected] Received 29 October 2013; accepted 26 April 2014.
obstetric care however the evidence for this is lacking. Our aim was to explore the relationship between perineal outcome and postpartum PFD, and examine the influence of PFD on quality of life (QOL).
Materials and Methods We performed a prospective cohort study at The Townsville Hospital, a 420-bed tertiary hospital that performs 2400 deliveries per annum. For inclusion participants had to be primiparous with a non-instrumental delivery from 1 January 2011 to 31 December 2012. Exclusion criteria were women whose baby died during labour or in the peripartum period. Women were identified using the hospital’s obstetric database Matrix; this database is updated and maintained during and after pregnancy and contributes to statewide data collection. The Townsville Hospital moved from paper to electronic records late in 2010 and thus the sample size was chosen empirically, using collated and validated data available in Matrix. Participants were divided into three groups based on their perineal outcome as reported in Matrix: intact perineum; episiotomy; and spontaneous tear.
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
371
J. Rikard-Bell et al.
Participants were mailed a self-reported QOL questionnaire at least six months after childbirth which consisted of short forms of the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). The questionnaire was administered to all groups twice, 14 weeks apart to increase the response rate; women were requested not to return a completed questionnaire twice. ANOVA was performed to compare the three groups of perineal trauma and the impact of PFD on their QOL. The post hoc Games–Howell test was performed where ANOVA was significant; significance was accepted at the 5% level. Outliers were excluded from analysis to gain more reliable results using ANOVA; outliers were identified using descriptive statistics, the data were inspected to ensure no errors and the individual data points removed. This study was approved by the Townsville Hospital Health Service Human Research Ethics Committee and Research Governance Office. This study also received approval for access and use of specified confidential information under the Public Health Act 2005.
Results Of the 766 women recruited, 79% had perineal injury, 60% had a spontaneous tear and 19% had an episiotomy (Table 1). Five per cent sustained severe perineal trauma (a third- or fourth-degree tear). Table 2 illustrates the clinical characteristics of the three groups; birthweight and stage two duration were greatest where perineal trauma occurred. 196 women returned a completed questionnaire; 97% of these women complained of symptoms of PFD.
Urinary symptoms Eighty-two per cent of women reported urinary symptoms causing bother. Sixty-three percent experienced urinary incontinence (UI); 50% had urine leakage related to coughing, sneezing or laughing, whilst 39% complained of small amounts of urine leakage. Women with an intact perineum reported the highest rate of UI (71%), followed by a spontaneous tear (66%) and then an episiotomy (60%). Overall, women who had an episiotomy reported Table 1 Perineal outcomes for primiparous women with a noninstrumental vaginal delivery (n = 766) Perineal outcome
n
%
Intact perineum Spontaneous tears 1st degree 2nd degree 3rd degree 4th degree Episiotomy Mediolateral Lateral Midline
163 458 156 280 18 4 145 136 5 4
21 60 20 37 2 1 19 18 0.5 0.5
372
the least amount of bother from urinary symptoms, whilst those with a spontaneous tear were most distressed (Table 3); ANOVA (Table 4) and post hoc Games– Howell test (Table 5) indicate that the mean urinary distress (UDI-6) score for women with an episiotomy is significantly lower than that of intact perineum and spontaneous tear (F2,194 = 7.69, P = 0.01).
Colorectal anal symptoms Seventy-nine per cent of women experienced bowel symptoms causing bother. Thirty-nine percent complained of anal incontinence (AI); 34% were incontinent of gas, 18% were incontinent of loose stool and 10% incontinent of solid stool. Women with an intact perineum reported the highest rate of AI (44%), followed by a spontaneous tear (37%) and then an episiotomy (35%); similar rates of incontinence of gas were found in all perineal outcomes, however the involuntary loss of loose and well-formed stool for women with an episiotomy was almost half that of women with other perineal outcomes. However, this study was unable to demonstrate a difference between the groups for overall bother caused by bowel symptoms (F2,194 = 1.13, P = 0.33) (Tables 3 and 4).
Pelvic organ prolapse Nine per cent of women complained of symptoms of pelvic organ prolapse (POP) impacting on their QOL, defined by a bulge seen or felt in the vaginal area. Women with an intact perineum reported the lowest rate of POP symptoms causing bother (6%), followed by an episiotomy (9%) and a spontaneous tear (13%). An association between perineal trauma and bother caused by POP was unable to be confirmed in this study (F2,194 = 0.19, P = 0.82) (Tables 3 and 4).
Sexual dysfunction Ninety-eight percent of women complained of sexual dysfunction. The most frequent symptoms were dyspareunia (70%) and negative emotional reactions to sexual intercourse (56%). Thirty-three per cent avoided sexual intercourse because of UI and 10% because of POP. Twenty-two percent were always satisfied with the variety of sexual activities, 24% felt sexually excited during intercourse and 16% climaxed when having intercourse with their partner, for 31% this was less intense than the previous six months. No association between perineal trauma and the impact of sexual dysfunction on QOL was demonstrated in this study (F2,194 = 0.45, P = 0.64) (Tables 3 and 4).
Discussion Perineal trauma is the most common complication associated with vaginal delivery. Compared to Queensland statistics, our rates of perineal trauma were slightly higher
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Perineal outcome and the pelvic floor Table 2 Maternal and fetal characteristics of the sample population (n = 766) Intact perineum
Oxytocin stimulation Yes No Epidural anaesthesia Yes No Maternal birthing position Upright Recumbent Other/Unknown Accoucheur Midwife Obstetrician or Obstetrics Registrar Student midwife Registered Medical Officer or Medical student Maternal age (years)† Gestational age (weeks)† Maternal weight (kg)†,‡ Fetal birthweight (g)† Stage two duration (min)†
Episiotomy
Spontaneous tear
n = 163
%
n = 145
%
n = 458
%
42 121
26 74
54 91
54 56
153 305
33 67
3 160
2 98
10 135
7 93
26 432
6 94
25 135 3
15 83 3
2 141 2
1 98 1
47 394 17
10 86 4
84 51 14 9 59 36 6 4 23.4 (16–41) 39 (26–42) 70.0 (40–148) 3058 (915–4580) 39.9 (0–171)
77 53 29 20 33 23 4 4 24.8 (16–38) 40 (30–42) 71.1 (40–130) 3410 (1551–4360) 65.5 (0–247)
262 57 14 3 155 34 27 6 24.4(15–40) 39 (29–42) 74.1 (39–150) 3381 (1418–4730) 47.6 (0–256)
†Median (range). ‡Note 17 women had missing data for maternal weight.
Table 3 Means and standard deviations comparing groups of perineal outcome on quality of life (QOL) scales n
Mean
SD
Urinary Distress Inventory – 6 (UDI-6) Intact perineum 60 40.56 14.37 Episiotomy 41 32.11 6.54 Spontaneous tear 86 36.25 9.26 Colorectal Anal Distress Inventory – 8 (CRADI-8) Intact perineum 59 35.91 10.72 Episiotomy 43 33.21 6.99 Spontaneous tear 86 35.66 10.38 Pelvic Organ Prolapse Distress Inventory – 6 (POPDI-6) Intact perineum 53 29.95 4.91 Episiotomy 45 29.76 4.78 Spontaneous tear 85 30.39 6.89 Pelvic Floor Distress Inventory – 20 (PFDI-20) Intact perineum 59 60.57 57.15 Episiotomy 46 56.13 48.56 Spontaneous tear 89 55.71 51.97 Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire – 12 (PISQ-12) Intact perineum 57 7.44 3.64 Episiotomy 41 8.08 3.43 Spontaneous tear 90 8.07 4.79
(79 vs 70%); whilst spontaneous tears occurred slightly more frequently in our women (60 vs 59%), episiotomy was performed more often (19 vs 11%).1
Pelvic floor dysfunction is very common in the immediate postpartum period; it tends to remit by six months2 although in a considerable number of cases it does persist and the management of vaginal delivery appears to offer an opportunity to reduce its morbidity.4 Amongst our population, PFD was present after the sixth month postpartum in 98% of women. Urinary symptoms causing bother were reported by 82% of our women. UI, reported by 63% of women, was the most common complaint; 50% reported some degree of stress urinary incontinence (SUI) and 41% a degree of urge urinary incontinence (UUI). This compares well with rates reported in the literature.5,6 Women with an episiotomy reported the lowest rate of UI while those with an intact perineum reported the highest rate. UI is thought to result from loss of support and suspension provided by pelvic fascia, connective tissue and pelvic floor muscles; indirect damage to the nerves of the pelvic floor and bladder may also be implicated.4 Vaginal delivery was confirmed as a key risk factor for SUI in two identical twin sister studies.7,8 Episiotomy widens the vaginal opening for delivery of the fetus, reducing the distortion of pelvic floor tissues required for vaginal delivery. It therefore seems plausible that failure to perform an episiotomy is a risk factor for pelvic relaxation and subsequent development of UI. Furthermore, anterior perineal trauma occurs less often where an episiotomy is performed, suggesting that it may protect against trauma in this region.3 In this study, the lowest rate of UI was seen in women who had an
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
373
J. Rikard-Bell et al.
Table 4 ANOVA summary table comparing groups of perineal outcome on quality of life (QOL) scores df
SS
MS
Urinary Distress Inventory – 6 score Between groups 2 1772 886 Within groups 191 21176 115 Total 193 22949 Colorectal Anal Distress Inventory – 8 score Between groups 2 218 109 Within groups 191 17886 97 Total 193 18104 Pelvic Organ Prolapse Distress Inventory – 6 score Between groups 2 114 7 Within groups 191 6246 35 Total 193 6260 Pelvic Floor Distress Inventory – 20 score Between groups 2 918 459 Within groups 191 533269 2792 Total 193 534188 Pelvic Organ Prolapse/Urinary Incontinence Sexual – 12 score Between groups 2 16 8 Within groups 191 3255 18 Total 193 3271
F
P
7.69
0.01
1.13
0.33
0.19
0.82
0.16
0.85
Questionnaire 0.45
0.64
df, degrees of freedom; SS, sums of squares; MS, mean of squares; F, between group differences; P, probability.
Table 5 Games–Howell test comparing groups of perineal outcome on UDI-6 scores Mean difference
UDI-6 score Intact perineum Episiotomy Spontaneous tear
Episiotomy Spontaneous tear Intact perineum Spontaneous tear Intact perineum Episiotomy
8.44 4.30 8.44 4.14 4.30 4.14
SE
P
2.12 2.11 2.12 1.43 2.12 1.43
