Cesarean section in the second delivery to prevent anal incontinence after asymptomatic obstetrical anal sphincter injury: the EPIC multicenter randomized trial

OBJECTIVE To determine whether planned cesarean section (CS) for a second delivery protects against anal continence in women with obstetrical anal sphincter lesions. DESIGN Randomized trial SETTING: 6 maternity units in the Paris area. SAMPLE Women at high risk of sphincter lesions (first delivery with 3d 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 randomized to planned CS or vaginal delivery (VD). MAIN OUTCOME MEASURES Anal continence at 6 months post-partum. Secondary outcomes were urinary continence, 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 randomized to planned VD and 110 to planned CS. At 6-8 weeks after delivery, there was no significant difference in anal continence between the 2 groups. At 6 months after delivery, median Vaizey scores of anal continence were 1 [IQR 0-4] in the CS group and 1 [IQR 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 obstetrical 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.