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

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.