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Delivery method, anal sphincter tears and fecal incontinence: new information on a persistent problem

Wheeler, Thomas L II; Richter, Holly E

Current Opinion in Obstetrics and Gynecology: October 2007 - Volume 19 - Issue 5 - p 474–479
doi: 10.1097/GCO.0b013e3282ef4142

Purpose of review To review the risk factors for anal sphincter tears during vaginal delivery and their association with fecal incontinence symptoms.

Recent findings Recent evidence links sphincter tears with fecal incontinence, which has a significant negative impact on quality of life. The Childbirth and Pelvic Symptoms cohort study reported that the incidence and severity of fecal incontinence was increased in primiparous women experiencing a sphincter tear. Risk factors for tear included forceps, occiput posterior, vacuum delivery, prolonged second stage of labor and epidural. Using cesarean delivery to prevent fecal incontinence has not been justified, but the confluence of these risk factors in the context of labor management may be important in deciding on earlier intervention with cesarean delivery. Internal anal sphincter defects impact fecal incontinence, highlighting the identification and repair of the internal anal sphincter for future research and clinical applications. Routine episiotomy (or instrumentation) is not warranted, and there is no clear advantage to mediolateral episiotomy or overlapping sphincter repair. Postpartum ultrasound of the sphincter complex may have an emerging role.

Summary The modifiable risk factors of routine episotomy and instrumented delivery are associated with sphincter tear; definitive recommendations for labor management remain unclear in preventing fecal incontinence.

Department of Obstetrics and Gynecology, Division of Women's Pelvic Medicine and Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA

Correspondence to Thomas L. Wheeler II, MD, University of Alabama at Birmingham, Division of Women's Pelvic Medicine and Reconstructive Surgery, 619 19th Street South, NHB 219, Birmingham, AL 35249-7333, USA Tel: +1 205 996 2182; fax: +1 205 975 8893; e-mail:

© 2007 Lippincott Williams & Wilkins, Inc.