Caesarean section in the second delivery to prevent anal incontinence after asymptomatic obstetric anal sphincter injury: the EPIC multicentre randomised trial.

OBJECTIVE: To determine whether planned caesarean section (CS) for a second delivery protects against anal incontinence in women with obstetric anal sphincter lesions. DESIGN: Randomised trial. SETTING: Six maternity units in the Paris area. SAMPLE: Women at high risk of sphincter lesions (first delivery with third-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 randomised to planned CS or vaginal delivery (VD). MAIN OUTCOME MEASURES: Anal incontinence at 6 months postpartum. Secondary outcomes were urinary incontinence, 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 randomised to planned VD and 110 to planned CS. At 6-8 weeks after delivery, there was no significant difference in anal continence between the two groups. At 6 months after delivery, median Vaizey scores of anal incontinence were 1 (interquartile range 0-4) in the CS group and 1 (interquartile range 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 obstetric 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. TWEETABLE ABSTRACT: Caesarean section for the second delivery did not protect against anal incontinence in women with asymptomatic obstetric anal sphincter lesions.

[Decision making on breech delivery: information as a way to reconcile maternal autonomy and medical responsibility]. / Peut-on concilier autonomie maternelle et responsabilité médicale dans les décisions de voies d'accouchement des foetus en siège? Rôle de l'information.

As far as breech vaginal delivery remains an acceptable option, each case has to be evaluated in order to determine whether in that particular situation it is medically relevant. When vaginal delivery is to be envisaged, maternal consent is needed. This implies seeking medical information that allows women to express their autonomy and to be part of the decision regarding their delivery. This article concerns a physicians reflection on medical information and on connections between the obstetrician's responsibility, that of the future mother, and autonomy. Understanding information as necessarily arising from an exchange between the care giver and the future mother is the condition that allows the coexistence of maternal autonomy and medical responsibility.