Nursing Times Continence Award 2006
The 2006 Continence Award went to Rona Mackenzie, Clinical Nurse Specialist (CNS) –
Continence, West Essex PCT and Alison Clubb, Continence Link Midwife, Princess
Alexandra Hospital Trust (PAH), for their work in establishing a system of care for
women living in West Essex and the hospital catchment area, who sustain obstetric anal
sphincter trauma.
It was in 1999, that several young women with faecal incontinence presented at nurse led
continence clinics in West Essex. All had experienced a difficult vaginal delivery in the
previous six months, but had not been identified as having an anal sphincter tear. These
incidents were the trigger for developing the present system of care. The case note details
of these women were presented at a clinical risk meeting in the Maternity Department
and it was agreed to audit the existing provision of obstetric care for perineal trauma.
Many deficiencies in the system were identified. These included the absence of
guidelines and a rate of only 20% attendance by women sustaining recognised anal
sphincter trauma for a post natal check at the hospital. As a result, the outcome of the
injury repair and subsequent continence related problems was unknown to the people
undertaking the repairs. Therefore, under the existing system, it was difficult to improve
the standards of care for these women.
A multi-disciplinary working party was established, guidelines were written, education
was accessed by the CNS – Continence and education was provided for all doctors and
midwives via study days, audit meetings and clinical risk meetings. It was agreed that all
women sustaining recognised anal sphincter trauma, those who had experienced a
traumatic delivery or had concerns about their bowel control would be referred to the
Continence Advisory Service and offered an appointment to be seen at approximately 6
weeks following delivery. The attendance rate improved to 85% immediately, with many
of those not attending, ringing to cancel their appointment as they were symptom free.
Women were seen, assessed, given advice and treatment as required. Those with
persistent problems or requiring further investigations were referred back to their
obstetrician and / or colorectal surgeon.
One of the initial problems was that of failure of delivery staff to recognise damage to the
anal sphincter. There is now a considerable body of evidence that supports the statement
that many obstetricians and midwives lack the necessary education to enable them to do
so. The rate of anal sphincter trauma reported in research papers in late 1990’s early
2000’s was 1-2%, although work by Abdul Sultan published in 1993 identified that 1 in 3
women who have a vaginal delivery sustain trauma to their anal sphincter. These
conflicting figures raised questions of concern. Within our unit the rate has risen from
0.86% in 2003 to 2.34% in 2005. This is less likely to be an increase in tear rate and more
likely to be better identification of the tears which occur. Midwives are discouraged from
viewing the occurrence of an anal sphincter tear as a negative reflection on their
management of the delivery. Not all tears are associated with a midwifery led delivery.
There is a higher incidence rate in women who have an assisted delivery, i.e. with
Ventouse or forceps, which are performed by doctors. The incidence of anal sphincter
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tears may be reduced, but cannot be avoided. The important fact is that any injury must
be clearly identified and properly repaired, with good aftercare.
Regular annual audits have been undertaken and the results presented to doctors and
midwives. The audits check obstetric notes for adherence to guidelines and continence
service notes for symptoms of anal incontinence, treatment and advice. The initial rate of
anal incontinence in the 1999 audit was 73% with urgency of stool being the most
common symptom, a 27% incidence of soiling associated with urgency and problems
controlling flatus experienced by 55% of the women. By the 2005 audit, the rates had
dropped to 35% urgency of stool, 6% soiling with urgency and 12% problems controlling
flatus. The symptoms experienced by the women in the 2005 audit were mostly resolved
by 6 months post delivery.
As with any project aimed to change care within an organisation, it takes time and effort.
Changes in medical and midwifery staffing, reduction in the number of available
midwives and reduction in funding for education are factors that continue to pose
problems, which have to be overcome. This project was developed within the existing
resources of the Continence Advisory Service and Obstetric Unit, so is not dependant on
additional annual funding. The CAS is community based but has a service level
agreement with the Acute Trust so allowing for easy working arrangements and
collaboration. The referrals to the Continence Advisory Service have steadily increased
from 17 in 2001 to 52 in 2005 and have been absorbed into the workload without
difficulty. All women referred are seen by the CNS – Continence. This has enabled the
development of the expertise required to deal with these women and provide a high
standard of care.
The development of a Continence Link Midwife post has given momentum to the work.
Alison Clubb was a member of the original working party and has been involved
throughout. She undertook the ENB 978 and additional education to be able to provide
support to staff in the working environment. She links closely with the Continence
Advisory Service, reports on problems or women who the doctor or midwife has undue
concerns about, and fast tracks women who need an earlier appointment. She has now
taken over the responsibility for regular staff education within the Maternity Unit.
Problems identified by the CNS – Continence are relayed to Alison for necessary action
and in conjunction with Chris Edwards, Clinical Risk Midwife, arrangements are made
for presentation at clinical risk meetings.
The regular auditing of the notes of women who attend clinic following sphincter injury
has enabled us to identify other problems that periodically occur, e.g. problems with
delay in the rate that the suture material dissolves within the tissues. By recognising this,
women can be reassured and an explanation given of what is within a normal range of
events and that if there is persistent discomfort or pain on intercourse, these symptoms
need to be reported. Another problem reported by some of the women was that of loose
uncontrollable stools when taking the laxatives prescribed to avoid constipation.
Laxatives are routinely prescribed for 7 days, but now the women are given a copy of the
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Bristol Stool Scale and advised to titrate the dose in order to achieve a controllable soft
stool.
Doctors and midwives give attention to the physical aspects of care, but without the
opportunity to attend a specialised clinic it may be difficult to identify the psychological
impact that this injury has on some women and in some instances their partner. Very few
women have any idea that their bowel continence mechanism may be damaged during a
vaginal delivery and information given at the time of delivery and repair is difficult to
comprehend and remember. An explanation of the nature of the damage, repair and
normal bowel function gives the women the information with which to participate in their
care and the recovery process.
Irrespective of the degree of damage and resulting symptoms, many women will have
concerns about the state of their perineum and resuming intercourse and so require
support and advice. All women who have sustained anal sphincter trauma or have anal
incontinence, need to advise their midwife or obstetrician if they become pregnant again.
Careful assessment of the situation and possibly investigations will be required, in order
to determine if a vaginal delivery or caesarean section is the safest option. Women have
access to a variety of sources of information in this age of technology, not all of which
are reliable, and so can have difficulties in making choices. Several women, pregnant
again, have returned to clinic to discuss the options prior to or following their visit to the
obstetrician.
This system of care is part of the care provided to all women who experience recognised
anal sphincter trauma within our unit and women who live in West Essex who have their
baby in a hospital out of area. The benefit of this system is that it is integrated in to the
standards of care for women who delivery within the unit. It is recognised and supported
by the doctors, midwives, managers and the Continence Advisory Service. The women
appreciate and value the time taken to ensure that they are fit for the future and can access
information and advice if problems reoccur. As a team we are willing to undertake
regular reviews, make adaptations or changes as required.
Rona Mackenzie
CNS – Continence
Email rona@brianmac.demon.co.uk
References on request
Sultan AH et al (1993) Anal sphincter disruption during vaginal delivery. N Engl J Med;
329:1905-11
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