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

Incontinence occurs frequently in the postpartum period. Several theoretical pathophysiological models may underlie the hypothesis that different types of management of the active phase of the second stage of labor have different effects on pelvic floor muscles and thus perhaps affect urinary and anal continence. We aimed to evaluate the impact of "moderate pushing" on the occurrence of urinary or anal incontinence compared to "intensive pushing" and then to determine the factors associated with incontinence at 6 months postpartum. This was a planned analysis of secondary objectives of the PASST (Phase Active du Second STade) trial, a multicenter randomized controlled trial. PASST included nulliparous women with singleton term pregnancies and epidural analgesia, who were randomly assigned at 8 cm of dilatation to either the intervention group that used “moderate” pushing (pushing only twice during each contraction, resting regularly for one contraction in five without pushing, and no time limit on pushing) or the control group following the usual management of “intensive” pushing (pushing three times during each contraction, with no contractions without pushing, with an obstetrician called to discuss operative delivery after 30 minutes of pushing). Data about continence were collected with validated self-assessment questionnaires at 6 months postpartum. Urinary incontinence was defined by an ICIQ-UI SF (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form) score >0 and anal incontinence by a Wexner Score ≥2. A separate analysis was also performed among the more severely affected women (ICIQ-UI SF ≥6 and Wexner ≥5). Factors associated with incontinence were assessed with univariate and multivariable analyses. Among 1618 women initially randomized, 890 (55%) returned the complete questionnaire at 6 months. The rate of urinary incontinence was 36.6% in the "moderate” pushing group versus 38.5% in the “intensive” pushing group (RR, 0.95; 95% CI, 0.80-1.13), while the rate of anal incontinence was 32.2% versus 34.6% (RR, 0.93; 95% CI, 0.77-1.12). None of the obstetric factors studied related to the second stage of labor influenced the occurrence of urinary or anal incontinence, except operative vaginal delivery, which increased the risk of anal incontinence (aOR, 1.50; 95% CI, 1.04-2.15). The results of the PASST trial indicate that neither moderate nor intensive pushing efforts affect the risk of urinary or anal incontinence