Urinary problems

Symptoms of stress incontinence are the most common of the urinary problems that occur in association with childbirth, but some women also have retention and voiding difficulties or urinary tract infection. If urine has not been voided by 6 hours following the birth and measures, such as a warm bath or shower, are not immediately successful, the bladder should be palpated and catheterization should be considered as urgent action needs to be taken (NICE 2006). The bladder can only contain a certain amount of urine even when distended, and once that capacity is reached, the sphincter of the bladder relaxes and urine escapes. This is referred to as retention with overflow.

Urinary voiding difficulties and retention are generally immediate post-delivery complications. Zaki et al (2004) found that I in 60 women failed to resume normal voiding during the immediate postpartum period. Their national survey found that there was no consensus about the diagnostic criteria for retention or the optimum management for voiding dysfunction. Further research is needed, as, if it is not recognized, bladder overdistension can lead to denervation, detrusor atony and bladder dysfunction requiring, in extreme cases, self-catheterization for up to 5 weeks (Zaki et al 2004). Zaki et al reported that retention is being reported with increasing frequency, which could be due to greater awareness or an increasing use of epidural analgesia and instrumental deliveries. From day 2 onwards, pelvic floor exercises should be taught, to prevent any involuntary leakage of urine, especially if a woman reports leaking small amounts of urine. Persistent urinary incontinence should be referred for investigation and treatment (NICE 2006). A third of women are known to suffer from the problem following childbirth. Pelvic floor exercises will reduce the incidence, especially with one-to-one teaching and supervision. The exercises may be particularly beneficial for women who give birth to large babies or who have forceps deliveries (Hay-Smith et al 2008).

General population studies have shown that urinary stress incontinence among women, defined as the involuntary leakage of urine caused by pressure on the bladder from coughing, sneezing, laughing and exertion, is widely experienced (Pollock 2004). Childbirth is generally considered to be the most common cause. Viktrup & Lose (2001) reported a prevalence of stress incontinence 5 years after a first delivery of 30%, and the risk of stress incontinence at this time was related to the onset and duration of symptoms after the first pregnancy and delivery. The use of vacuum extraction or episiotomy during the first delivery also increased the risk. In their follow-up study, Glazener et al (2005) also found that about three-quarters of the women with urinary incontinence at 3 months after childbirth still had the problem 6 years later. They concluded that the moderate short-term benefits of conservative treatment may not persist. Further research is required so that appropriate management strategies can be identified. Women should be encouraged to discuss the problems of incontinence so that they can receive the advice and support that is currently available.

The risk factors in the aetiology of stress incontinence remain unclear, but it is generally considered to be linked to pelvic floor innervation damage (Allen et al 1990, Zaki et al 2004) which is more common after a longer second stage labour and the delivery of a bigger baby. Increasing maternal age, heavier infant birthweight and larger head circumference have also been identified as risk factors by Wilson et al (1996). Findings relating to the effect of forceps have been inconsistent (Brown & Lumley 1998). Delivery by caesarean section is generally associated with a lower prevalence of stress incontinence (Assassa et al 2000, Wilson et al 1996). However, Wilson et al (1996) found that a reduced occurrence only applied to women who had up to two caesarean sections.

The severity of postpartum stress incontinence and its effect on lifestyle appear to be variable. Many women practise pelvic floor exercises ineffectively and some not at all, since doing the exercises competes with all the other demands in the immediate postnatal period. A trial of treatment using pelvic floor exercise education given to women who had persistent stress incontinence at 3 months postpartum found a significant reduction in the number who still had the symptoms at 12 months (Glazener et al 2001).

There is limited information on the postpartum occurrence of urinary tract infections. Glazener et al (1995) found that 5% of women reported a urinary tract infection some time during the first postpartum year. A postpartum urinary tract infection is more common after a caesarean section and a recent Cochrane systematic review has shown that prophylactic antibiotics for women who have abdominal deliveries are effective in reducing the occurrence (Smaill & Hofmeyr 2010).

Bowel problems

Constipation is common following delivery as the pain of perineal trauma or reduced dietary intake in labour can predispose to it. The few studies that have documented the prevalence of constipation have indicated that it occurs at some time following about 15–20% of births (Glazener et al 1995, Saurel-Cubizolles et al 2000), and is more common after instrumental delivery than after spontaneous vaginal or caesarean deliveries (Glazener et al 1995).

Haemorrhoids are also known to be common after childbirth, and faecal incontinence as well as anal fissure sometimes occur. Haemorrhoids can be extremely painful, but it has generally been considered that most cases regress within a few days of the birth (CKS 2005). However, childbirth-associated haemorrhoids can be longer lasting, with between 15% and 20% of women reporting symptoms at about 2 months after the birth (Glazener et al 1995).

Management should be as per local protocol, but severe, swollen or prolapsed haemorrhoids should be evaluated (NICE 2006). MacArthur et al (1991) found that two-thirds of the women with haemorrhoids still had them at least a year after giving birth, indicating that complete resolution of childbirth-related haemorrhoids is not common. The severity of persisting symptoms, however, is not known. Longer second stage of labour and heavier infant birthweight are associated with an increased likelihood of haemorrhoids (MacArthur et al 1991). Glazener et al (1995) found that they were more than twice as common after instrumental compared with spontaneous vaginal delivery and that women were much less likely to experience haemorrhoids after caesarean section delivery.

One study documented anal fissure, defined as a split or tear in the skin of the anal canal, as occurring in 9% of the women (Corby et al 1997). The authors noted that, without detailed investigation, many of these would have been diagnosed (if at all) as acute painful haemorrhoids, with over 90% of cases resolving without treatment. Type of delivery or perineal trauma were not associated with the occurrence of anal fissure, but postnatal constipation was much more common in the symptomatic group, which is why it is so important that midwives accurately identify and assess this problem by sensitive questioning of the woman. Midwives must also advise women on diet to ensure stools are soft and easily passed. After repair of a third or fourth degree laceration, several weeks of therapy with a stool softener, such as docusate sodium (colace), to minimize the potential for repair breakdown from straining during defecation, is recommended. Pain relief must be offered to reduce the risk of this adding to the fear of defecation (Premkumar 2005).

The occurrence of postpartum faecal incontinence, including frank incontinence, soiling and faecal urgency, is increasingly being documented. One factor associated with the development of faecal incontinence is birth injury, in particular third or fourth degree tear or disruption of the external anal sphincter muscle (Christianson et al 2003, Fenner et al 2003, Sultan et al 1999). Estimates of prevalence of faecal incontinence range from 17% to 62% if there has been severe perineal trauma at delivery, or forceps delivery. Prophylactic antibiotics can be helpful in preventing infection and breakdown of perineal wounds following third or fourth degree tears and reducing the risk of faecal incontinence (Duggal et al 2008). In addition to third or fourth degree tears, the main risk factor for postpartum faecal incontinence is instrumental delivery (Assassa et al 2000, MacArthur et al 1997, MacArthur et al 2001).

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