Photo Credit: Gorodenkoff

The following is a summary of “Moderate or intensive management of the active phase of second-stage labor and risk of urinary and anal incontinence: results of the PASST randomized controlled trial,” published in the NOVEMBER 2023 issue of Obstetrics and Gynecology by Dupuis, et al.

Incontinence is a common issue in the postpartum period, with various theoretical pathophysiological models suggesting that different management approaches during the active phase of the second stage of labor may impact pelvic floor muscles, potentially influencing urinary and anal continence. For a study, researchers sought to assess the influence of “moderate pushing” in comparison to “intensive pushing” on the occurrence of urinary or anal incontinence. Additionally, the objective was to identify factors associated with incontinence at 6 months postpartum.

The study represented a planned secondary analysis of the PASST (Phase Active du Second STade), a multicenter randomized controlled trial. The trial focused on nulliparous women with singleton-term pregnancies and opted for epidural analgesia. Participants were randomly assigned at 8 cm of dilatation to either the intervention group employing “moderate” pushing or the control group following the standard practice of “intensive” pushing. In the intervention group, participants pushed only twice during each contraction, took regular breaks (resting for 1 contraction in 5 without pushing), and had no time limit on pushing. The control group adhered to the conventional method of pushing, involving three pushes during each contraction, with no contractions without pushing. Additionally, an obstetrician was consulted to discuss operative delivery after 30 minutes of pushing. Data regarding continence were collected through validated self-assessment questionnaires administered at the 6-month postpartum mark. Urinary incontinence was defined by an ICIQ-UI SF (International Consultation on Incontinence Questionnaire–Urinary Incontinence Short Form) score ≥1, while anal incontinence was defined by a Wexner score ≥2. A separate analysis was conducted specifically for more severely affected women, identified by ICIQ-UI SF ≥6 and Wexner ≥5. Factors associated with incontinence were evaluated through univariate and multivariable analyses, providing insights into the potential contributors to postpartum incontinence among the study participants.

Of the 1,618 initially randomized women in the PASST trial, 890 (55%) provided complete questionnaire responses at the 6-month follow-up. Urinary incontinence was 36.6% in the “moderate” pushing group, while it was slightly higher at 38.5% in the “intensive” pushing group. The relative risk for urinary incontinence between the two groups was 0.95 (95% confidence interval, 0.80–1.13). Similarly, the rates of anal incontinence were 32.2% in the “moderate” pushing group and 34.6% in the “intensive” pushing group, with a relative risk of 0.93 (95% CI, 0.77–1.12). Notably, none of the obstetrical factors related to the second stage of labor were found to influence the occurrence of urinary or anal incontinence, except for operative vaginal delivery, which increased the risk of anal incontinence (adjusted odds ratio, 1.50; 95% CI, 1.04–2.15).

The findings derived from the PASST trial suggested that neither moderate nor intensive pushing efforts significantly impacted the risk of urinary or anal incontinence at the 6-month postpartum mark among women who underwent epidural analgesia during childbirth.

Source: ajog.org/article/S0002-9378(23)00506-9/fulltext