Original Research ajog.

org

OBSTETRICS
Mode of delivery after obstetric anal sphincter injury and
the risk of long-term anal incontinence
Hanna Jang, MD; Jens Langhoff-Roos, MD, DMSc; Susanne Rosthj, MSc, PhD; Abelone Sakse, MD, PhD

BACKGROUND: Primiparous women have an increased risk of ob-
stetric anal sphincter injury; because most of these patients deliver again,
there are major concerns about mode of delivery: the risk of recurrent
obstetric anal sphincter injury and the risk of long-term symptoms of anal
incontinence. Although an elective cesarean delivery protects against
recurrent obstetric anal sphincter injury, it is uncertain how the second
delivery affects the risk of long-term anal incontinence.
OBJECTIVE: The purpose of this study was to evaluate whether the
mode of delivery for a second pregnancy, after a documented obstetric
anal sphincter injury at the time of first delivery, had a significant impact on
the prevalence of anal and fecal incontinence in the long term.
STUDY DESIGN: We performed a population-based questionnaire
cohort study that evaluated anal and fecal incontinence, fecal urgency,
and affected quality of life caused by anal incontinence in 1978 patients
who had obstetric anal sphincter injury in the first delivery and a second
vaginal (n 1472 women; 71.9%) or elective cesarean delivery (n 506
women; 24.7%) delivery. We performed uni- and multivariable logistic
regression analyses to compare groups.
RESULTS: Long-term anal incontinence was reported in 38.9% of
patients (n 573) with second vaginal compared with 53.2% (n 269)
with elective cesarean delivery. The corresponding numbers that reported
anal incontinence before the second pregnancy was 29.4% for those
with vaginal delivery compared with 56.2% of those with elective cesarean
delivery (ie, there was a significantly larger change in the risk of anal
incontinence in the group with a second vaginal delivery compared with
the change in the group with elective cesarean in second delivery).
However, adjusted for important maternal and obstetric characteristics,
the risk of long-term anal incontinence was nonsignificantly lower in
patients with elective cesarean delivery (adjusted odds ratio, 0.77;
95% confidence interval, 0.57e1.05; P .09). Furthermore, the risk of
fecal incontinence was not affected by mode of delivery in the multivariable
analysis (adjusted odds ratio, 1.04; 95% confidence interval, 0.76e1.43;
P .79). Patients with persistent anal incontinence before the
second pregnancy (n 496) had an increased risk of long-term anal
incontinence (adjusted odds ratio, 64.70; 95% confidence interval,
42.85e97.68; P < .001) and long-term fecal incontinence (adjusted odds
ratio, 13.76, 95% confidence interval, 10.03e18.88, P<0.001)
compared with patients without anal incontinence before the second
pregnancy.
CONCLUSION: Mode of second delivery did not significantly affect the
risk of long-term anal or fecal incontinence in multivariable analyses of
patients with previous obstetric anal sphincter injury in this population in
which patients with anal incontinence before the second pregnancy were
recommended to have an elective cesarean delivery in the subsequent
delivery. Nonetheless, we found that patients with vaginal delivery had a
higher risk of deterioration of anal incontinence symptoms compared with
those with an elective cesarean delivery.
Key words: anal incontinence, cesarean delivery, fecal incontinence,
mode of second delivery, obstetric anal sphincter injury

O bstetric anal sphincter injuries

(OASIS) are serious complications
to vaginal deliveries and cause long-term
anal incontinence (AI), which is dened
as involuntary leakage of atus, liquid,
and/or solid stool, in up to 50% of the
patients.1-4 In Denmark, the risk of
OASIS in primiparous women has been
increasing from 6.1% in 2000 to 7.4% in
2010.5 In second pregnancies, patients
with previous OASIS have 2 main con-
cerns: the risk of recurrent OASIS and
the risk of the development of AI after
Cite this article as: Jango H, Langhoff-Roos J, Rosthj S,
et al. Mode of delivery after obstetric anal sphincter injury
and the risk of long-term anal incontinence. Am J Obstet
Gynecol 2016;214:733.e1-13.
0002-9378/$36.00
2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2015.12.030
second delivery. In Denmark, the risk of
recurrent OASIS is 7.1% (95% con-
dence interval, 6.5e7.7%).6 Some studies
have found that a second vaginal delivery,
with or without recurrent OASIS, in-
creases the risk of AI,1,7-11 whereas others
have found that second vaginal delivery
does not increase the risk.12,13 Moreover,
1 of these studies found that recurrent
OASIS does not increase the risk of AI.12
These results question that second
vaginal delivery and recurrent OASIS
increases the risk of AI in patients with
OASIS. However, most of these studies
have a small number of included patients,
and only a few studies have investigated
whether an elective cesarean delivery
(CS) in the second pregnancy protects
against long-term AI when compared
with a vaginal delivery.2,13
Accurate information to patients with
OASIS is necessary to give appropriate
counseling regarding long-term out-
comes. Our primary objective was to
evaluate whether the mode of second
delivery, after a documented OASIS at
the time of rst delivery, had a signicant
impact on the prevalence of AI and
fecal incontinence (FI) after the second
delivery.
Materials and Methods
We performed a postal questionnaire
cohort survey and included all women
with 2 consecutive deliveries from
January 1, 1997, to December 31, 2005,
in Denmark where the rst delivery was
complicated by OASIS. The question-
naire was sent to all women in the study
between September 15, 2010, and May
31, 2011. The study was approved by the
Danish National Board of Health (J.nr.
7-505-29-1562), and written informed
consent was obtained by all participants.

JUNE 2016 American Journal of Obstetrics & Gynecology 733.e1

Original Research OBSTETRICS
OASIS was classied according to the
Royal College of Obstetricians and
Gynaecologists classication where a
third-degree OASIS is dened as a partial
or complete disruption of the anal
sphincter muscles, which may involve
either or both the external and internal
anal sphincter muscles; a fourth-degree
OASIS is dened as a disruption of the
anal sphincter muscles with a breach of
the rectal mucosa.14 OASIS was identi-
ed by the International Classication of
Diseases, 10th edition, codes O70.2 and
O70.3 or by the surgical code KMBC33
from the Danish medical birth registry.
These codes in the registry have been
validated by medical records in the
same time period.15 In the analyses, we
were not able to differentiate between
partial and complete third-degree OASIS
because this differentiation was not
present in the Danish Medical Birth
Registry at this time.
The questionnaire was based on a
validated questionnaire by Due and
Ottesen.16 The questionnaire included
questions regarding AI and related
symptoms only and was divided in 2
sections. In the rst, we asked the pa-
tients whether they had experienced AI
in the time period between the rst de-
livery with OASIS until the onset of the
second pregnancy (yes/no); AI was clas-
sied as incontinence of atus, liquid,
and/or solid stool, and information was
retrieved on whether the AI persisted
until the onset of the second pregnancy
(Did you experience leakage [inconti-
nence] of gas or feces when you became
pregnant with your second child? [yes/
no]). These answers were then merged
into 1 category with 3 possible answers:
no AI before the second pregnancy/
transient AI before the second preg-
nancy/persistent AI at the onset of the
second pregnancy. This rst section was
included to adjust for the occurrence of
AI before the second pregnancy, because
the obstetrics practice in Denmark is to
recommend elective CS if the patient
experiences transient or persisting AI
after a rst delivery with OASIS. In the
second section of the questionnaire that
concerned current symptoms only, we
asked questions regarding fecal urgency
(dened as inability to defer defecation
733.e2 American Journal of Obstetrics & Gynecology JUNE 2016
for 15 minutes), difculty to wipe clean
after defecation, ability to differentiate
between gas and stool in the rectum,
whether they experienced anal pain
during or after defecation, and whether
they experienced AI. Those who experi-
enced AI were asked to differentiate
the type of AI in atus incontinence,
incontinence of liquid, and/or inconti-
nence of solid stool. Patients were
also asked whether they experienced
fecal leakage without realizing this
until later and if the AI affected their
quality of life. The questionnaire was
validated by interviews and test-retest.
Patients were sent a reminder after
1 month.
Based on results by Nordenstam et al,1
we performed a power calculation
(Supplemental Table 1) to detect differ-
ences regarding severe incontinence
(dened as involuntary loss of atus for
>1/week or daily or loss of feces (with
any frequency))1 between those women
with vaginal delivery or elective CS. We
found that 2000 patients were needed
to obtain a power of 80%.
Data regarding obstetric and maternal
characteristics regarding rst and second
delivery were obtained from the Danish
Medical Birth Registry. Patients with
premature delivery, patients with >2
deliveries, breech presentation, inam-
matory bowel disease, patients who did
not understand written Danish, patients
with AI before rst delivery, patients
who had undergone surgical treatment
because of AI, and patients who did not
answer the rst section of the question-
naire were excluded. Moreover, we
excluded patients with emergency CS
(ie, those patients who were elected for
a trial of labor or planned vaginal
delivery that ended up with CS).
Both the questionnaire (Supplemental
Table 2) and the database (Supplemental
Table 3) were validated.
We evaluated 2 primary outcomes.
The rst primary outcome was long-
term AI (ie, a positive answer to the
question Do you experience involun-
tary leakage of gas or stool? [yes/no] at
the time of answering the questionnaire)
that was sent out several years after the
second delivery). The second primary
outcome was long-term FI (ie, FI at the
ajog.org
time of answering the questionnaire).
This outcome was based on 2 questions
(Do you experience involuntary leakage
of liquid stool? and Do you experience
involuntary leakage of solid stool?).
A positive answer to 1 or both of these
questions yielded a yes in the primary
FI outcome, whereas negative responses
to both questions yielded no. Second-
ary outcomes were responses to the
remaining specic questions regarding
other symptoms that were present at
the time of answering the questionnaire
(ie, long-term outcomes; Table 1).
Statistical methods
Differences between groups were exam-
ined with the use of the Mann-Whitney
test or the Fishers exact test. We per-
formed univariable logistic regression
analyses to determine crude odds ratios
and multivariable logistic regression
analyses to determine adjusted odds ra-
tios. Multivariable analyses were per-
formed to evaluate whether the mode of
the second delivery and other explana-
tory variables affected the primary out-
comes: long-term AI and FI or the
secondary outcomes (Table 1). The
multivariable analyses were adjusted for
important maternal and obstetric char-
acteristics: mode of second delivery
(vaginal or elective CS); maternal age
(per year); grade of OASIS in rst de-
livery (third- or fourth-degree); birth-
weight (per kilogram) in rst and second
delivery; and time period (per year) since
rst and second delivery. All these
explanatory variables were extracted
from the Danish Medical Birth Registry.
The multivariable analyses were also
adjusted for whether the patient re-
ported AI before the second pregnancy
(no AI/transient AI/persistent AI), based
on answers in the rst section of the
questionnaire.
In separate analyses, we included
another variable of AI before the second
pregnancy (no AI/atus incontinence/FI
before the second pregnancy). In these
analyses, the AI variable of no/transient/
persistent AI before the second preg-
nancy was excluded.
We also performed subgroup analyses
that included only patients with per-
sistent AI at the onset of the second
ajog.org
pregnancy to evaluate the effect of mode
of second delivery in this group.
Furthermore, we examined the
change in the proportion of women with
AI before the second pregnancy and AI at
long term with the use of the McNemar
test for those who delivered vaginally
and those who delivered by CS sepa-
rately. Whether the change was equal
for the 2 groups was assessed by a test of
homogeneity.17
Probability values of <.05 were con-
sidered signicant; however, because of
the large number of outcomes and ex-
posures, we did not focus on borderline
signicant probability values to avoid
spurious signicant ndings. Data were
analyzed with the use of the statistical
software R.18
Results
The questionnaire was sent to all patients
(n 3138) in Denmark with a second
delivery after a rst delivery with OASIS
from 1997-2005 to allow at least 5 years
of follow up since the second delivery. Of
these, 2432 patients returned the ques-
tionnaire (77.5%), and 1987 patients
met the inclusion criteria. Of these,
1739 patients (87.9%) had a third-degree
OASIS, and 239 patients (12.1%) had a
fourth-degree OASIS in the rst deliv-
ery. In the second delivery, 1472 patients
had a vaginal delivery; 506 patients
had an elective CS, compared with the
corresponding numbers of the non-
responders, 75.2% (vaginal delivery) and
20.4% (elective CS; P .012). De-
mographic data are presented in Table 2.
Mode of second delivery
Descriptive data that are based on an-
swers from the questionnaire, divided by
the mode of the second delivery, are
presented in Table 3. Long-term AI was
reported by 38.9% of patients (n 573)
with a second vaginal delivery and by
53.2% of patients (n 269) with elective
CS in the second delivery (P < .001).
Crude and adjusted odds ratio for long-
term AI and FI are presented in Table 4.
Patients with elective CS had a higher
risk of AI (53.3%; n 269; crude odds
ratio, 1.79; 95% condence interval,
1.46e2.19; P < .001) and FI (24.1%;
n 122; crude odds ratio, 1.98; 95%
OBSTETRICS Original Research
TABLE 1
Secondary long-term outcomes related to anal incontinence
Answer categories in Dichotomized
Secondary outcome the questionnaire answers for analysis
Incontinence of flatus Never No
Rarely Yes
Sometimes Yes
Often Yes
Always Yes
Fecal incontinence (liquid and/or solid Never No
stool)
Rarely Yes
Sometimes Yes
Often Yes
Always Yes
Affected quality of life because of anal Not at all No
incontinence
Some Yes
Severely Yes
Fecal urgency 15 minutes Yes/No
Fecal leakage without realizing this until Yes/No
afterwards
Ability to differentiate between gas or Yes/No
feces in the rectum
Anal pain in relation to or after Yes/No
defecation
Difficulties to wipe clean after Yes/No
defecation
Jang et al. Mode of delivery after obstetric sphincter injury. Am J Obstet Gynecol 2016.
condence interval, 1.54e2.55; P < in the risk of long-term was signicantly
.001) than patients with second vaginal different when we compared the change
delivery (AI, 38.9% [n 573]; FI, 13.9% between the 2 groups (P < .001; ie, there
[n 204]). However, in the multivari- was a signicantly larger change in the
able analyses, elective CS was not asso- group with a second vaginal delivery
ciated with a higher risk of long-term AI compared with the change in the group
(adjusted odds ratio, 0.77; 95% con- with elective CS in second delivery).
dence interval, 0.57e1.05; P .09) or FI
(adjusted odds ratio, 1.04; 95% con- AI before the onset of the second
dence interval, 0.76e1.43; P .79; pregnancy
Supplemental Table 1). Overall, 36.6% of the patients (n 749)
We compared the risk of AI before reported AI before the second preg-
second delivery with the risk of AI at nancy; 22.2% of them (n 440) had
long term (Table 5). For those with atus incontinence only; 13.5% of them
vaginal delivery in second delivery, (n 268) reported FI. Figure describes
29.4% reported AI before the second distribution of patients regarding mode
pregnancy; 38.9% reported AI at long of second delivery based on whether AI
term (P < .001). The corresponding was present before the second preg-
numbers for those with elective CS were nancy. In patients with intended vaginal
56.2% and 53.3% (P .16). The change delivery, 30.1% (n 464) reported AI
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Original Research OBSTETRICS ajog.org

TABLE 2
Demographic data for patients with obstetric anal sphincter injury in the first delivery and a second vaginal delivery or
an elective cesarean delivery in the second delivery
Vaginal delivery Elective cesarean
Variables Missing (n 1472) delivery (n 506) P valuea
Age when answering questionnaire, yb 0 39.1 (36.5-41.6) 38.8 (36.5-41.3) .32
Time since obstetric anal sphincter injury in first delivery, yb 0 11.8 (10.4-13.4) 11.2 (10.0-12.7) < .001
Time since second delivery, yb 0 8.7 (7.3-10.4) 8.3 (7.0-9.4) < .001
b
Delivery interval, y 0 2.8 (2.2-3.4) 2.8 (2.3-3.5) .41
Variables regarding first delivery
Maternal age, yb 0 28.6 (26.4-30.8) 28.6 (26.7-31.2) .19
Birthweight, gb 11 3720 (3426-4006) 3865 (3539-4200) < .001
Gestational age, db 0 284 (279-290) 284 (279-290) .96
Head circumference, cm b
50 36 (35-27) 36 (35-27) < .001
Length, cmb 14 53 (52-54) 53 (52-55) .009
Presentation 67 .95c
Occiput anterior 1371 (93.1) 471 (93.1)
Occiput posterior 52 (3.5) 17 (3.4)
Type of obstetric anal sphincter injury, n (%) 0 < .001c
Third degree obstetric anal sphincter injury 1356 (92.1) 383 (75.7)
Fourth degree obstetric anal sphincter injury 116 (7.9) 123 (24.3)
Vacuum extraction, n (%) 0 526 (35.7) 205 (40.5) .06c
Forceps, n (%) 0 7 (0.5) 4 (0.8) .48c
Cervical suture, n (%) 0 15 (1.0) 7 (1.4) .47c
Induction of labor, n (%) 0 106 (7.2) 56 (11.1) .008c
Mediolateral episiotomy, n (%) 0 344 (23.4) 159 (31.4) .001c
Oxytocin augmentation, n (%) 0 244 (15.2) 84 (16.6) .48c
Shoulder dystocia, n (%) 0 26 (1.8) 27 (5.3) .001c
Variables regarding second delivery
Maternal age, yb 0 31.6 (29.4-33.9) 31.9 (29.7-34.3) .10
Birthweight, g b
8 3760 (3470-4080) 3600 (3300-3866) < .001
Gestational age, d b
0 282 (277-287) 271 (269-273) < .001
c
Head circumference, cm 39 36 (35-37) 36 (35-37) .18
Length, cmc 15 53 (52-54) 52 (51-53) < .001
a
Mann-Whitney test; b Data are given as medians (interquartile range); c Fishers exact test.
Jang et al. Mode of delivery after obstetric sphincter injury. Am J Obstet Gynecol 2016.

before the second pregnancy; in patients
who had elective CS, the proportion was
signicantly higher, 56.3% (n 285).
Patients with AI before the second
pregnancy not only were at increased
risk of AI and FI at long term but also
had a higher risk of almost all of the
secondary outcomes compared with
patients without AI before the second
pregnancy. The general trend was that
patients with FI before the second
pregnancy had even worse outcome
(higher adjusted odds ratios) regarding
FI and most of the other secondary
outcomes (Supplemental Table 2).
Patients who reported AI before the
second pregnancy were divided into 2
groups based on whether they reported
transient (n 440; 22.2%) or persistent
AI (n 268; 13.5%) at the onset of the
second pregnancy. These patients were
compared with patients who reported
no AI before the second pregnancy.
We evaluated whether the groups with
transient and persistent AI before the
second pregnancy had the same risk for
the various outcomes (data not shown)
and found that their risks of the ability
to differentiate between gas and stool in
the rectum and their risk of anal pain

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ajog.org OBSTETRICS Original Research

TABLE 3
Questionnaire answers about anal incontinence among patients with obstetric anal sphincter injury and a second
vaginal delivery or an elective cesarean delivery in second delivery
Vaginal delivery Elective cesarean
Outcome Missing (n 1472) delivery (n 506) P valuea
Symptoms before the second pregnancy
Anal incontinence, n (%) 0 433 (29.4) 285 (56.3) < .001
Type of anal incontinence, n (%) 1 < .001
Flatus incontinence 284 (19.3) 156 (30.8)
Liquid stool 113 (7.7) 96 (19.0)
Solid stool 29 (2.0) 30 (5.9)
Persistent anal incontinence at the onset of the second 6 290 (19.7) 206 (40.7) < .001
pregnancy, n (%)
Duration of transient flatus incontinence before the 12 6 (0.5-30) 6 (1-36) .70c
second pregnancy, mob
Duration of transient fecal incontinence before the second 7 4 (0.3-48) 3 (1-24) .51c
pregnancy, mob
Long-term symptoms, n (%)
Anal incontinence 1 573 (38.9) 269 (53.2) < .001
Fecal incontinence 1 204 (13.9) 122 (24.1) < .001
Flatus incontinence 6 543 (36.9) 259 (51.2) < .001
Incontinence of liquid stool 3 186 (12.6) 113 (22.3) < .001
Incontinence of solid stool 2 71 (4.8) 41 (8.1) .007
Fecal leakage without noticing until later 9 57 (3.9) 31 (6.1) .05
Fecal urgency <15 minutes 6 407 (27.6) 181 (35.8) .001
Difficulties wiping clean after defecation 28 526 (35.7) 258 (51.0) < .001
Inability to differentiate between gas or stool in the rectum 34 151 (10.3) 62 (12.3) .21
Anal pain during or after defecation 24 245 (16.6) 116 (22.9) .002
Affected quality of life because of anal incontinence 4 365 (24.8) 210 (41.5) < .001
a
Fishers exact test; b Data are given as medians (range); c Mann-Whitney test.
Jang et al. Mode of delivery after obstetric sphincter injury. Am J Obstet Gynecol 2016.

during or after defecation were equal.
However, the risk of AI, FI, and the
remaining secondary outcomes differed;
generally, the group with persistent AI
had an increased risk compared with
those with transient AI before the second
pregnancy (Supplementary Table 3).
In subset analyses that included only
patients with persistent AI before the
second pregnancy, we did not nd that
mode of second delivery affected the risk
of long-term AI (P .19) or FI (P .37).
However, we found that more patients
with elective CS in the second delivery
reported affected quality of life because
of AI (81.6% [n 168] vs 69.7% [n
202]; P .007) compared with patients
with a second vaginal delivery. Mode
of second delivery did not affect the
remaining long-term outcomes in this
group (Supplemental Table 4).
Interactions
We evaluated interactions between AI
before the second pregnancy (yes/no)
and mode of second delivery for the
primary and secondary outcomes. The
effect of AI before the second pregnancy
was not modied by the mode of de-
livery for any of the outcomes.
Comment
In a large population-based question-
naire study of patients with OASIS in
the rst delivery, we found that mode of
delivery did not impact long-term AI or
FI symptoms after the second delivery
when patients with AI symptoms before
the second pregnancy were recom-
mended CS and patients without AI
before the second pregnancy were rec-
ommended vaginal delivery.
Several studies have found that a
second vaginal delivery increases the
risk of long-term AI.1,8,9,19 In contrast,
other studies have found that a second
vaginal delivery did not increase the
risk of AI,12,20 and another study
found that a second vaginal delivery
only increased the risk of severe AI in
patients with fourth-degree OASIS.21

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Original Research OBSTETRICS ajog.org

TABLE 4
Unadjusted and adjusted odds ratios for long-term anal incontinence and long-term fecal incontinence in 1978
patients with obstetric anal sphincter injury in the first delivery and 1 second deliverya
Univariable analyses (n 1978) Multivariable analyses (n 1959)a,b
Unadjusted 95% Confidence Adjusted 95% Confidence
Explanatory variables odds ratio interval P value odds ratio interval P value
Primary outcome: long-term anal incontinence
Mode of second delivery
Vaginal 1 1
Elective cesarean delivery 1.79 1.46-2.19 < .001 .77 .57-1.05 .09
Obstetric anal sphincter injury in first delivery
Third degree 1 1
Fourth degree 2.01 1.53-2.64 < .001 1.95 1.35-2.82 < .001
c,d
Anal incontinence before the second pregnancy
No anal incontinence 1 1
Transient anal incontinence 3.40 2.52-4.57 < .001 3.69 2.72-5.02 < .001
Persistent anal incontinence 59.33 39.82-88.37 < .001 64.70 42.85-97.68 < .001
Maternal age at long-term follow up (per year) 1.02 1.00-1.05 .030 1.04 1.01-1.08 .02
Birthweight first child (per kg)e 1.31 1.08-1.61 .006 1.12 .84-1.49 .46
f
Birthweight second child (per kg) 1.17 0.96-1.42 .11 1.35 1.01-1.79 .04
Time since first delivery (per year) 1.00 0.95-1.05 .96 1.05 .93-1.17 .42
Time since second delivery (per year) 1.00 0.96-1.05 .89 .96 .85-1.08 .47
Primary outcome: long-term fecal incontinence
Mode of second delivery
Vaginal 1 1
Elective cesarean delivery 1.98 1.54-2.55 < .001 1.04 .76-1.43 .79
Obstetric anal sphincter injury in first delivery
Third degree 1 1
Fourth degree 2.60 1.90-3.51 < .001 2.28 1.58-3.30 < .001
Anal incontinence before the second pregnancyc,d
No anal incontinence 1 1
Transient anal incontinence 3.87 2.53-5.88 < .001 4.06 2.64-6.24 < .001
Persistent anal incontinence 13.84 10.29-18.84 < .001 13.76 1.03-18.88 < .001
Maternal age at long-term follow up (per year) 1.04 1.01-1.08 .004 1.05 1.01-1.09 .01
e
Birthweight first child (per kg) 1.21 0.93-1.57 .16 1.04 .74-1.45 .83
f
Birthweight second child (per kg) 0.95 0.74-1.23 .70 1.05 .75-1.46 .79
Time since first delivery (per year) 1.07 1.00-1.14 .041 1.21 1.06-1.38 .004
Time since second delivery (per year) 1.04 0.98-1.11 .22 .88 .77-1.01 .07
a
Multivariable analyses were adjusted for all explanatory variables presented in this Table; N 1957 in multivariable analysis for long-term fecal incontinence; N 1971 in the univariable
b c

analysis; d Overall probability value of association of <.001 for both the univariable and multivariable analysis; e N 1968 in the univariable analysis; f N 1970 in the univariable analysis.
Jang et al. Mode of delivery after obstetric sphincter injury. Am J Obstet Gynecol 2016.

Most follow-up studies are small and might be advisable to avoid aggrava- affected the risk of long-term AI or FI
do not include patients with CS in the tion of AI.21,22 and that it is possible that it is the rst
second delivery1,8,9,19; however, some In our adjusted analyses, we did not delivery with OASIS that is the most
studies conclude that an elective CS nd that the mode of second delivery important predictor of long-term AI10,23

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ajog.org OBSTETRICS Original Research

TABLE 5
Distribution of patients reporting anal incontinence between the first delivery with obstetric anal sphincter injury and
the onset of the second pregnancy and patients reporting anal incontinence at long-term, divided by mode of second
delivery (vaginal delivery or elective cesarean delivery
Long-term follow up, n (%)
Time period between first delivery with obstetric
anal sphincter injury and the onset of the No anal Flatus Incontinence of Incontinence of
second pregnancy incontinence incontinence liquid stool solid stool Total
Second delivery: vaginal (n 1468)
No anal incontinence 819 (55.8) 170 (11.6) 37 (2.5) 19 (1.3) 1045 (71.2)
Flatus incontinence 61 (4.2) 157 (10.7) 43 (2.9) 20 (1.4) 281 (19.1)
Incontinence of liquid stool 29 (2.0) 20 (1.4) 48 (3.3) 16 (1.1) 113 (7.7)
Incontinence of solid stool 5 (0.3) 4 (0.3) 4 (0.3) 16 (1.1) 29 (2.0)
Total 914 (62.3) 351 (23.9) 132 (9.0) 71 (4.8) 1468
Second delivery: elective cesarean delivery (n 504)
No anal incontinence 178 (35.3) 31 (6.2) 8 (1.6) 7 (1.4) 224 (44.4)
Flatus incontinence 36 (7.1) 91 (18.1) 21 (4.2) 6 (1.2) 154 (30.6)
Incontinence of liquid stool 19 (3.8) 13 (2.6) 48 (9.5) 16 (3.2) 96 (19.0)
Incontinence of solid stool 7 (1.4) 7 (1.4) 4 (0.8) 12 (2.4) 30 (6.0)
Total 240 (47.6) 7 (28.2) 4 (0.8) 12 (2.4) 504
Jang et al. Mode of delivery after obstetric sphincter injury. Am J Obstet Gynecol 2016.

or that the second pregnancy affects the
risk of AI more than the mode of second
delivery. However, in the unadjusted
analyses, we found a relatively larger
increase in the risk of AI for those with
vaginal delivery. This underlines the
challenge of interpreting results from
multivariable analyses to recommenda-
tions in the daily clinical practice.
We found that a second vaginal de-
livery compared with elective CS did
not increase the risk of long-term AI in
patients with persistent AI at the onset
of the second pregnancy. Bek and
Laurberg7 found, in a small study, that
transient AI after an OASIS was the
only predictor of long-term AI after a
second vaginal delivery. Fynes et al10
found that persistent FI in primipa-
rous patients was a risk factor of dete-
rioration of AI after a second vaginal
delivery. They stated that pudendal
nerve damage is cumulative in vaginal
deliveries and recommended that an
elective CS is preferable if the patient
has persistent AI. However, none of
these studies included a control group
of patients with elective CS in
the second pregnancy.
Danish guidelines recommend an
elective CS in second delivery for pa-
tients with OASIS if the patient has
experienced symptoms of AI. To enable
correction for this possible indication
bias, patients were asked whether they
have had symptoms of AI before the
onset of the second pregnancy. The an-
swers to the questions in the rst section
of the questionnaire might therefore be
affected by recall bias, because all pa-
tients who were included in this study
delivered 5 years ago. However, the
same risk of recall bias applies for all
participants, regardless of the mode of
second delivery, and all questions
regarding the long-term outcomes were
not subjected to recall bias. Nonetheless,
the underlying bias of this study, that
recommendation of mode of delivery
based on whether the patient experi-
enced AI before the second pregnancy,
cannot be removed completely by the
multivariable logistic regression models
that were used in this study.
This is the largest study that evaluates
long-term AI in a population of patients
with OASIS in the rst delivery and
1 subsequent vaginal delivery or CS.
Nordenstam et al1 has previously shown
that AI 5 years after delivery with OASIS
is predictive of AI after 10 years and that
the prevalence of AI remained un-
changed from 5-10 years of follow up.
Our study population represents pre-
menopausal patients, for whom other
possible risk factors of AI (ie, age,
menopause) are of limited importance.
By time, it is plausible that symptoms of
AI worsen, and our prevalence of AI
underestimates those in an older popu-
lation. The subgroup analyses might be
underpowered to detect differences be-
tween groups. Other limitations are the
lack of objective measurements and in-
formation about medication that might
affect the anal sphincter tone.
The retrospective study design is
clearly a limitation, and a randomized
controlled trial that randomly assigns
patients with OASIS to either vaginal
delivery or elective CS in a second de-
livery irrespective of symptoms of AI
before the second pregnancy would be
preferable, but obviously not feasible.
Based on our results, we can inform
patients with AI before the second
pregnancy that they have an increased

JUNE 2016 American Journal of Obstetrics & Gynecology 733.e7

Original Research
FIGURE
Flow chart
Flow chart shows the mode of second delivery in relation to symptoms of anal incontinence in
the time period between first delivery with obstetric anal sphincter injury and until the onset of the
second pregnancy
AI, anal incontinence; CS, cesarean delivery; OASIS, obstetric anal sphincter injury.
Jang et al. Mode of delivery after obstetric sphincter injury. Am J Obstet Gynecol 2016.
risk of long-term AI, regardless of the
mode of second delivery. Even though
elective CS was not protective in the
adjusted analyses regarding long-term
AI or FI in this population (where pa-
tients with AI before the second preg-
nancy were recommended elective CS in
subsequent deliveries), patients with
vaginal delivery had a higher risk of
deterioration of AI symptoms compared
with those with an elective CS. n Gynecol 2014;210:59.e1-6.
References
1. Nordenstam J, Altman D, Brismar S,
Zetterstrm J. Natural progression of anal in-
continence after childbirth. Int Urogynecol J
Pelvic Floor Dysfunct 2009;20:1029-35.
2. Wegnelius G, Hammarstrm M. Complete
rupture of anal sphincter in primiparas: long-
term effects and subsequent delivery. Acta
Obstet Gynecol Scand 2011;90:258-63.
3. Soerensen MM, Bek KM, Buntzen S,
Hjberg K-E, Laurberg S. Long-term outcome
733.e8 American Journal of Obstetrics & Gynecology JUNE 2016
OBSTETRICS
of delayed primary or early secondary recon-
struction of the anal sphincter after obstetrical
injury. Dis Colon Rectum 2008;51:312-7.
4. Bols EMJ, Hendriks EJM, Berghmans BCM,
Baeten CGMI, Nijhuis JG, de Bie RA.
A systematic review of etiological factors for
postpartum fecal incontinence. Acta Obstet
Gynecol Scand 2010;89:302-14.
5. Jang H, Langhoff-Roos J, Rosthj S,
Sakse A. Modiable risk factors of obstetric anal
sphincter injury in primiparous women: a
population-based cohort study. Am J Obstet
6. Jang H, Langhoff-Roos J, Rosthj S,
Sakse A. Risk factors of recurrent anal sphincter
ruptures: a population-based cohort study.
BJOG 2012;119:1640-7.
7. Bek KM, Laurberg S. Risks of anal inconti-
nence from subsequent vaginal delivery after a
complete obstetric anal sphincter tear. BJOG
1992;99:724-6.
8. Faltin DL, Sangalli MR, Roche B, Floris L,
Boulvain M, Weil A. Does a second delivery in-
crease the risk of anal incontinence? BJOG
2001;108:684-8.
9. Fornell EU, Matthiesen L, Sjdahl R, Berg G.
Obstetric anal sphincter injury ten years after:
ajog.org
subjective and objective long term effects.
BJOG 2005;112:312-6.
10. Fynes M, Donnelly V, Behan M,
OConnell PR, OHerlihy C. Effect of second
vaginal delivery on anorectal physiology and
faecal continence: a prospective study. Lancet
1999;354:983-6.
11. Sze EHM. Prevalence and severity of anal
incontinence in women with and without addi-
tional vaginal deliveries after a fourth-degree
perineal laceration. Dis Colon Rectum 2005;48:
66-9.
12. Sze EHM. Anal incontinence among women
with one versus two complete third-degree
perineal lacerations. Int J Gynaecol Obstet
2005;90:213-7.
13. Scheer I, Thakar R, Sultan AH. Mode of
delivery after previous obstetric anal sphincter
injuries (OASIS): a reappraisal? Int Urogynecol
J Pelvic Floor Dysfunct 2009;20:1095-101.
14. Third- and Fourth-degree Perineal Tears,
Management (Green-top Guideline No. 29).
Royal College of Obstetricians & Gynaecolo-
gists. Availab at: https://www.rcog.org.uk/en/
guidelines-research-services/guidelines/gtg29/.
Accessed: January 13, 2015.
15. Langhoff-Roos J, Rasmussen S. Sund-
hedsstyrelsen Center for Evaluering og Medi-
cinsk Teknologivurdering C: Validering af
Landspatientregisteret (LPR) mhp obstetrisk
forskning og kvalitetssikring: - et kvalitetsud-
viklingsprojekt. Kbenhavn: CEMTV; 2003.
16. Due U, Ottesen M. The Danish anal
sphincter rupture questionnaire: validity and
reliability. Acta Obstet Gynecol Scand 2009;88:
36-42.
17. Zhao YD, Rahardja D, Wang D-H, Shen H.
Testing homogeneity of stratum effects in strat-
ied paired binary data. J Biopharm Stat
2014;24:600-7.
18. R: The R Project for Statistical Computing. R
Core Team (2015), R: A language and environ-
ment for statistical computing, R Foundation for
Statistical Computing, Vienna, Austria. Available
at: http://www.r-project.org/. Accessed: July 2,
2015.
19. Poen AC, Felt-Bersma RJ, Strijers RL,
Dekker GA, Cuesta MA, Meuwissen SG. Third-
degree obstetric perineal tear: long-term clinical
and functional results after primary repair. Br J
Surg 1998;85:1433-8.
20. De Leeuw JW, Vierhout ME, Struijk PC,
Hop WC, Wallenburg HC. Anal sphincter dam-
age after vaginal delivery: functional outcome
and risk factors for fecal incontinence. Acta
Obstet Gynecol Scand 2001;80:830-4.
21. Sangalli MR, Floris L, Faltin D, Weil A.
Anal incontinence in women with third or fourth
degree perineal tears and subsequent vaginal
deliveries. Aust N Z J Obstet Gynaecol 2000;40:
244-8.
22. McKenna DS, Ester JB, Fischer JR. Elective
cesarean delivery for women with a previous
anal sphincter rupture. Am J Obstet Gynecol
2003;189:1251-6.
23. Sultan AH, Kamm MA, Hudson CN,
Bartram CI. Third degree obstetric anal
ajog.org OBSTETRICS Original Research

sphincter tears: risk factors and outcome of
primary repair. BMJ 1994;308:887-91.
Author and article information
From the Department of Obstetrics and Gynecology,
Herlev University Hospital (Dr Jango); the Department of
Obstetrics and Gynecology, Juliane Marie Centre,
Rigshospitalet, University Hospital (Drs Langhoff-Roos
and Sakse), and the Section of Biostatistics, Institute of
Public Health, University of Copenhagen (Dr Rosthj),
Copenhagen, Denmark.
Received Oct. 3, 2015; revised Nov. 29, 2015;
accepted Dec. 16, 2015.
Supported by the Aase and Ejnar Danielsens Foun-
dation, Kgs. Lyngby, Denmark.
The authors report no conflict of interest.
Presented as preliminary results at the 38th Nordic
Congress of Obstetrics and Gynecology, Bergen, Norway,
June 16-19, 2012.
Corresponding author: Hanna Jango, MD. hanna@
jango.se

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SUPPLEMENTAL TABLE 1
Multiple multivariable analyses regarding long-term outcomes that are related to anal incontinence dependent on
mode of second delivery (vaginal or elective cesarean delivery) after a first delivery with obstetric anal sphincter
injurya
Adjusted 95% Confidence
Outcome N Mode of second delivery odds ratio interval P value
Anal incontinence 1959 Vaginal delivery 1
Elective cesarean delivery 0.77 0.57e1.05 .09
Fecal incontinence 1957 Vaginal delivery 1
Elective cesarean delivery 1.04 0.76e1.43 .79
Incontinence of flatus 1954 Vaginal delivery 1
Elective cesarean delivery 0.83 0.62e1.11 .22
Affected quality of life because of anal 1956 Vaginal delivery 1
incontinence
Elective cesarean delivery 1.17 0.88e1.57 .29
Fecal urgency 1954 Vaginal delivery 1
Elective cesarean delivery 1.04 0.81e1.34 .74
Inability to differentiate between gas or 1933 Vaginal delivery 1
feces in the rectum
Elective cesarean delivery 0.97 0.68e1.37 .85
Fecal incontinence without noticing until 1952 Vaginal delivery 1
afterwards
Elective cesarean delivery 0.83 0.50e1.39 .47
Difficulties wiping clean after defecation 1933 Vaginal delivery 1
Elective cesarean delivery 1.52 1.21e1.91 < .001
Anal pain during or after defecation 1940 Vaginal delivery 1
Elective cesarean delivery 1.43 1.08e1.89 .011
a
The multivariable analyses were adjusted for maternal age, grade of obstetric anal sphincter injury in the first delivery (grade 3 or 4), anal incontinence before the second pregnancy (no/transient/
persistent), birthweight of first and second child, and years since first and second delivery.
Jang et al. Mode of delivery after obstetric sphincter injury. Am J Obstet Gynecol 2016.

733.e10 American Journal of Obstetrics & Gynecology JUNE 2016

ajog.org OBSTETRICS Original Research

SUPPLEMENTAL TABLE 2
Risk of long-term anal incontinenceerelated outcomes that are dependent on whether the patient reported anal
incontinence (no anal incontinence/flatal incontinence/fecal incontinence) before the second pregnancya
Anal incontinence before Adjusted 95% Confidence Overall
Outcome N the second pregnancy odds ratio interval P value P value
Anal incontinence 1952 No 1 < .001
Flatal incontinence 15.26 11.54e20.18 < .001
Fecal incontinence 15.38 10.92e21.67 < .001
Fecal incontinence 1950 No 1 < .001
Flatal incontinence 4.59 3.25e6.50 < .001
Fecal incontinence 30.25 20.86e43.86 < .001
Incontinence of flatus 1947 No 1 < .001
Flatal incontinence 13.30 10.14e17.43 < .001
Fecal incontinence 10.96 7.97e15.08 < .001
Affected quality of life because of anal 1949 No 1 < .001
incontinence
Flatal incontinence 11.52 8.81e15.05 < .001
Fecal incontinence 17.00 12.28e23.53 < .001
Fecal urgency 1947 No 1 < .001
Flatal incontinence 2.64 2.07e3.36 < .001
Fecal incontinence 6.28 4.69e8.41 < .001
Inability to differentiate between gas or 1927 No 1 < .001
feces in the rectum
Flatal incontinence 0.57 0.40e0.80 .002
Fecal incontinence 0.32 0.22e0.47 < .001
Fecal incontinence without noticing until 1945 No 1 < .001
afterwards
Flatal incontinence 2.97 1.52e5.80 .002
Fecal incontinence 17.11 9.54e30.68 < .001
Difficulties wiping clean after defecation 1927 No 1 < .001
Flatal incontinence 1.91 1.52e2.40 < .001
Fecal incontinence 3.03 2.29e4.03 < .001
Anal pain during or after defecation 1933 No 1 < .001
Flatal incontinence 1.47 1.10e1.96 .009
Fecal incontinence 2.70 1.97e3.70 < .001
a
The multivariable analyses were adjusted for maternal age, grade of obstetric anal sphincter injury in the first delivery (grade 3 or 4), birthweight of first and second child and years since first and
second delivery.
Jang et al. Mode of delivery after obstetric sphincter injury. Am J Obstet Gynecol 2016.

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Original Research OBSTETRICS ajog.org

SUPPLEMENTAL TABLE 3
Risk of long-term anal incontinenceerelated outcomes that are dependent on whether the patient reported anal
incontinence (no anal incontinence/transient anal incontinence/persistent anal incontinence) before the second
pregnancya
Anal incontinence before Adjusted 95% Confidence Overall
Long-term outcome N the second pregnancy odds ratio interval P value P value
Anal incontinence 1959 No 1 < .001
Transient anal incontinence 3.69 2.72e5.02 < .001
Persistent anal incontinence 64.70 42.85e97.68 < .001
Fecal incontinence 1957 No 1 < .001
Transient anal incontinence 4.06 2.64e6.24 < .001
Persistent anal incontinence 13.76 10.03e18.88 < .001
Incontinence of flatus 1954 No 1 < .001
Transient anal incontinence 3.41 2.50e4.63 < .001
Persistent anal incontinence 34.07 24.48e47.42 < .001
Affected quality of life because of 1956 No 1 < .001
anal incontinence
Transient anal incontinence 4.07 2.89e5.73 < .001
Persistent anal incontinence 24.88 18.76e32.99 < .001
Fecal urgency 1954 No 1 < .001
Transient anal incontinence 1.93 1.40e2.65 < .001
Persistent anal incontinence 4.70 3.72e5.93 < .001
Inability to differentiate between gas 1933 No 1 < .001
or feces in the rectum
Transient anal incontinence 0.58 0.37e0.92 .02
Persistent anal incontinence 0.40 0.29e0.56 < .001
Fecal incontinence without noticing 1952 No 1 < .001
until afterwards
Transient anal incontinence 3.44 1.56e7.62 .002
Persistent anal incontinence 8.90 5.11e15.53 < .001
Difficulties wiping clean after 1933 No 1 < .001
defecation
Transient anal incontinence 1.74 1.29e2.34 < .001
Persistent anal incontinence 2.58 2.07e3.23 < .001
Anal pain during or after defecation 1940 No 1 < .001
Transient anal incontinence 1.77 1.25e2.52 .001
Persistent anal incontinence 1.95 1.49e2.56 < .001
a
The multivariable analyses were adjusted for mode of second delivery, maternal age, grade of obstetric anal sphincter injury in the first delivery (grade 3 or 4), birthweight of first and second child,
and years since first and second delivery.
Jang et al. Mode of delivery after obstetric sphincter injury. Am J Obstet Gynecol 2016.

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ajog.org OBSTETRICS Original Research

SUPPLEMENTAL TABLE 4
Multivariable analyses of long-term anal incontinenceerelated outcomes that are dependent on mode of second
delivery (vaginal or elective cesarean delivery after a first delivery with obstetric anal sphincter injury in patients with
persistent anal incontinence before the second pregnancya
Adjusted 95% Confidence
Outcome N Mode of second delivery odds ratio interval P value
b
Anal incontinence 492 Vaginal delivery 1
Elective cesarean delivery 1.74 0.76e3.97 .19
Fecal incontinence 490 Vaginal delivery 1
Elective cesarean delivery 1.20 0.81e1.78 .37
b
Incontinence of flatus 489 Vaginal delivery 1
Elective cesarean delivery 1.68 0.89e3.18 .11
Affected quality of life because of anal 491 Vaginal delivery 1
incontinence
Elective cesarean delivery 1.90 1.19e3.02 .007
Fecal urgency 489 Vaginal delivery 1
Elective cesarean delivery 1.12 0.76e1.65 .57
Inability to differentiate between gas or 478 Vaginal delivery 1
feces in the rectum
Elective cesarean delivery 1.17 0.69e1.96 .56
Fecal incontinence without noticing until 488 Vaginal delivery 1
later
Elective cesarean delivery 1.03 0.57e1.88 .91
Difficulties wiping clean after defecation 488 Vaginal delivery 1
Elective cesarean delivery 1.28 0.86e1.91 .22
Anal pain during or after defecation 488 Vaginal delivery 1
Elective cesarean delivery 1.55 1.00e2.42 .05
a
The multivariable analyses were adjusted for maternal age, grade of obstetric anal sphincter injury in the first delivery (grade 3 or 4), birthweight of first and second child, and years since first and
second delivery; b This multivariable analysis was not adjusted for grade of obstetric anal sphincter injury in the first delivery because of limited numbers in each group.
Jang et al. Mode of delivery after obstetric sphincter injury. Am J Obstet Gynecol 2016.

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