Cesarean section in the second delivery to prevent anal incontinence
after asymptomatic obstetrical anal sphincter injury: the EPIC
multicenter randomized trial
Abstract
Objective: To determine whether planned cesarean section (CS) for a
second delivery protects anal continence in women with obstetrical anal
sphincter lesions. Design: Randomized trial. Setting: 6 maternity units
in the Paris area. Sample : Women at high risk of sphincter lesions
(first delivery with 3d degree laceration and/or forceps) but no
symptomatic anal incontinence. Methods : Endoanal ultrasound was
performed in the third trimester of the second pregnancy. Women with
sphincter lesions were randomized to planned CS or vaginal delivery
(VD). Main outcome measures : Anal continence at 6 months post-partum.
Secondary outcomes were urinary continence, sexual morbidity, maternal
and neonatal morbidities and worsening of external sphincter lesions.
Results : Anal sphincter lesions were detected by ultrasound in 264/434
women enrolled (60.8%) ; 112 were randomized to planned VD and 110 to
planned CS. At 6-8 weeks after delivery, there was no significant
difference in anal continence between the 2 groups. At 6 months after
delivery, median Vaizey scores of anal continence were 1 [IQR 0-4]
in the CS group and 1 [IQR 0-3] in the VD group (p = 0.34). There
were no significant differences for urinary continence, sexual functions
or for other maternal and neonatal morbidities. Conclusions : In women
with asymptomatic obstetrical anal sphincter lesions diagnosed by
ultrasound, planning a CS had no significant impact on anal continence 6
months after the second delivery. These results do not support advising
systematic CS for this indication.