Anal incontinence following birth injury - are we asking the right questions?

Sarah attends for the 8 week check with her baby, Alfie. You go out to the waiting room to call her, and there’s no answer. Another patient in the waiting room points to the toilet- ‘I think they’ve gone for a nappy change’, they say. Sarah emerges a few minutes later looking flustered. She scans the waiting room with an embarrassed look. 

Sarah has a lot of important questions about Alfie. Addressing these issues and doing the physical baby check takes most of the appointment. By this point Alfie’s crying, and Sarah is bouncing him around trying to get him to settle. 

You ask how she’s recovering physically after the birth, and receive a distracted ‘um ok’. Then follows a brief chat about support, mood, and contraception. Things are now running a bit late and the nurse is waiting to do the vaccinations. Sarah is off out of the door.

Only, it wasn’t the baby’s nappy that needed changing at the start of the consultation. It was Sarah that had to rush to the toilet due urgency and anal incontinence.

A qualitative study recently published in the BJGP explored the healthcare experiences of women with anal incontinence after childbirth injury (N=41). The second phase of the study considered the views of GPs (N=13).  An eye opener for me was that very few women suffering from anal incontinence in the post-natal period report discussing it with their GP. This helpful article offers some key insights into why this might be, and importantly what we can do to better support these patients.

Are we asking the right questions?

The 6-8 week post-natal check presents a key opportunity to ask about symptoms of anal incontinence, with the  NICE guideline NG194  specifically recommending assessment of bowel function as a component of the check. However, as in our example above, people in the study reported that the post-natal check often focused predominantly on the needs of the baby. ‘It was probably about eighty percent about the baby really’, ‘I still didn’t really touch on half of the stuff I was experiencing’.  The GP focus group reported time constraints as a barrier to a comprehensive assessment of the birthing parent, and many said they did not routinely ask about anal incontinence unless there was a specific indication.  This sits with broader findings published in the ‘Women’s Health Strategy for England’,  which reports  ‘concerns that postnatal support was often too focused on the health and wellbeing of the baby, sometimes to the exclusion of the mother’. 

Some women talked about how embarrassment was a barrier to discussing their symptoms with a GP. Direct questions from the GP were generally viewed as helpful, but needed to be sensitively broached and tailored to the patient. The GP focus group highlighted times that language barriers made communication more complex. We should be aware that Asian women are at higher risk, and use a professional translator where needed. 

In some cases, people may not be ready to talk about their symptoms the first time they are asked, or symptoms may progress over time. A key idea in the paper is enabling women to reconsult by ‘sowing the seed’. This involves core GP skills of reading subtle signs that there may be more to explore, active listening, and building trust over time. 

Although important to normalise asking about bowel incontinence it is vital to avoid implying that bowel incontinence is ‘normal’. Women reported feeling that their concerns were dismissed or ‘framed as being a ‘normal’ part of recovery from birth’. This led to some avoiding or delaying seeking further help. 

Those suffering with anal incontinence should be given a clear plan for managing their symptoms, and advice about how and when to seek a further review if simple measures are not effective. Treatment should be tailored to the patient, and may include advice about pelvic floor exercises and diet, referral to women’s health physiotherapists, gynaecology/colorectal pelvic floor clinic, and signposting to sources of support. The MASIC foundation has extensive resources for both patients and professionals, including a recent e-learning module produced in collaboration with the RCGP.

Take home message: we should ask routinely, specifically and sensitively about difficulty controlling bowels or wind after childbirth. Avoid suggesting that it is ‘normal’, and consider asking on more than one occasion.