Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.

Objectives To assess the effect of nurse assessment with reinforcement of pelvic floor muscle training exercises and bladder training compared with standard management among women with persistent incontinence three months postnatally. Design Randomised controlled trial with nine months' follow up. Setting Community intervention in three centres (Dunedin, New Zealand; Birmingham; Aberdeen). Participants 747 women with urinary incontinence three months postnatally, allocated at random to intervention (371) or control (376) groups. Intervention Assessment by nurses of urinary incontinence with conservative advice on pelvic floor exercises at five, seven, and nine months after delivery supplemented with bladder training if appropriate at seven and nine months. Main outcome measures Primary: persistence and severity of urinary incontinence 12 months after delivery. Secondary: performance of pelvic floor exercises, change in coexisting faecal incontinence, wellbeing, anxiety, and depression. Results Women in the intervention group had significantly less urinary incontinence: 167/279 (59.9%) v 169/245 (69.0%), difference 9.1% (95% confidence interval 1.0% to 17.3%, P = 0.037) for any incontinence and 55/279 (19.7%) v 78/245 (31.8%), difference 12.1% (4.7% to 19.6%, P = 0.002) for severe incontinence. Faecal incontinence was also less common: 12/273 (4.4%) v 25/237 (10.5%), difference 6.1% (1.6% to 10.8%, P = 0.012). At 12 months women in the intervention group were more likely to be performing pelvic floor exercises (218/278 (79%) v 118/244 (48%), P < 0.001). Conclusions A third of women may have some urinary incontinence three months after childbirth. Conservative management provided by nurses seems to reduce the likelihood of urinary and coexisting faecal incontinence persisting 12 months postpartum. Further trials for faecal incontinence are needed.

Objective To measure the prevalence and severity of postpartum faecal incontinence, especially new Design A cohort study with information on symptoms collected in home-based interviews and obstetric Setting Deliveries from a maternity hospital in Birmingham. Participants Nine hundred and six women interviewed a mean of 10 months after delivery. Main outcome measures New faecal incontinence starting after the birth, including frank incontinence, soiling and urgency.Results Thirty-six women (4%) developed new faecal incontinence after the index birth, 22 of whom had unresolved symptoms. Twenty-seven had symptoms several times a week, yet only five consulted a doctor. Among vaginal deliveries, forceps and vacuum extraction were the only independent risk factors: 12 (33%) of those with new incontinence had an instrumental delivery compared with 114 (14%) of the 847 women who had never had faecal incontinence. Six of those with incontinence had an emergency caesarean section but none became incontinent after elective sections.Conclusions Faecal incontinence as an immediate consequence of childbirth is more common than previously realised, and medical attention is rarely sought. Forceps and vacuum extraction deliveries are risk factors, with no protection demonstrated from emergency caesarean section. Identification and treatment is a priority.incontinence, and to identify obstetric risk factors.data from hospital casenotes.

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Objective To identify obstetric and other risk factors for urinary incontinence that occurs during pregnancy or after childbirth.Design Questionnaire survey of women.Setting Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand).Population A total of 3405 primiparous women with singleton births delivered during 1 year.Methods Questionnaire responses and obstetric case note data were analysed using multivariate analysis to identify associations with urinary incontinence.Main outcome measures Urinary incontinence at 3 months after delivery first starting in pregnancy or after birth.Results The prevalence of urinary incontinence was 29%. New incontinence first beginning after delivery was associated with older maternal age (oldest versus youngest group, OR 2.02, 95% CI 1.35-3.02) and method of delivery (caesarean section versus spontaneous vaginal delivery, OR 0.28, 95% CI 0.19-0.41). There were no significant associations with forceps delivery (OR 1.18, 95% CI 0.92-1.51) or vacuum delivery (OR 1.16, 95% CI 0.83-1.63). Incontinence first occurring during pregnancy and still present at 3 months was associated with higher maternal body mass index (BMI > 25, OR 1.68, 95% CI 1.16-2.43) and heavier babies (birthweight in top quartile, OR 1.56, 95% CI 1.12-2.19). In these women, caesarean section was associated with less incontinence (OR 0.39, 95% CI 0.27-0.58) but incontinence was not associated with age.Conclusions Women have less urinary incontinence after a first delivery by caesarean section whether or not that first starts during pregnancy. Older maternal age was associated with new postnatal incontinence, and higher BMI and heavier babies with incontinence first starting during pregnancy. The effect of further deliveries may modify these findings.