Introduction

Recent surveys from the United Kingdom and Australia examining obstetricians’ personal preferences towards delivery, both showed that approximately 1/3 of respondents would choose a Cesarean section for delivery [1, 2]. The major reason was the concern for possible pelvic floor damage. In the United States, a recent editorial from one of our leading journals asked the question as to whether the patients should be offered an elective cesarean section based on the increasing evidence of risk of pelvic floor disorders [3]. While there is considerable debate on this issue, there appears to be a consensus on the importance of informed consent regarding these risks [4]. The purpose of this study was to determine: whether patients receive information regarding pelvic floor complications; the source of the information and how this compares to the information given on general pregnancy topics.

Materials and methods

After IRB approval, women on the first post-partum day completed a 25-question, 52-item self-administered questionnaire. Women had delivered at a private hospital, which is the site of the university obstetrical service. They had received prenatal care from the resident clinic, faculty practice and private physicians. Permission was obtained from the private practitioners prior to approaching their patients. Two groups declined to have their patients included. This represents 4% of deliveries at the institution. It is unlikely that these patients differed significantly from the study population as the location of the doctor’s office was across the street from the hospital and close to the other doctors’ offices delivering at the hospital. A convenience sample of 239 surveys was administered. This depended entirely on when the medical students were able to have time off from their rotations to approach the patients. It was a different day on the various weeks. No patient who was approached, refused to participate. Exclusion criteria included: intrauterine, intrapartum or neonatal demise, gestation less than 32 weeks and inability to comprehend English. Questions were developed after reading literature on developing strategies for improving patient knowledge on screening for Down’s syndrome. Questionnaires were anonymous. Patients were not approached for clarification of their responses if they were incomplete. The date and bed number allowed the patient to be matched with their delivery data. A pilot study evaluated ten questionnaires to determine whether the questionnaire was easily understood and could be completed accurately. Of the 520 individual questions asked, nine responses (1.7%) were incomplete. We had predetermined that a completion rate of 98% would be acceptable.

The questionnaire consisted of two sections, the larger one consisting of 40 questions assessing the patient knowledge and the second relating to patient satisfaction with delivery and various risk scenarios. In an attempt to reduce potential bias, the patients were not informed of the purpose of the study and questions regarding pelvic floor knowledge were intermingled with questions regarding general pregnancy topics. Examples of the type of general question are as follows: did you receive any information during pregnancy on weight gain; did you receive any information during pregnancy on high blood pressure or early labor, contractions etc. Pelvic floor examples were; did you receive any information during pregnancy on Kegel exercises (pelvic floor exercises), stitches, episiotomy, leakage of urine, leakage of stool, larger size vagina after delivery, damage to the nerves down there (vagina) etc. Additionally, patients were asked from whom they received their information (choices—doctor, nurse, family/friends, magazines/internet). A more direct question was—“do you think that a C-section will help to prevent problems with leakage of urine or stool? Yes; No; Not sure.”

Statistical analysis was performed with SPSS 12.0 package (Statistical Package for Social Sciences, SPSS, Inc, Chicago, Il, USA). Differences between groups were analyzed using the Pearson chi-square test for categorical variables, and the independent samples t-test, with Levine’s test for equality of variances, for continuous variables. A P value <0.05 was used to define statistical significance.

Results

A total of 239 questionnaires were completed. Seven patients who did not receive prenatal care were excluded. The sociodemographic data is detailed in Table 1. The sample is representative of the delivery pattern of the hospital where, on a average, approximately 55% of deliveries are private and 45% from clinic service. Very few patients gave incomplete answers to the general questions with only 6/232 not answering two questions. The majority of patients received information during their pregnancy on the following topics: weight gain, hypertension, preterm labor, rupture of the membranes, Kegel exercises, sutures, Cesarean section, urinary frequency and incontinence. In contrast, less than half of the patients received any information on episiotomy, forceps or vacuum delivery, fecal incontinence, vaginal changes and neuropathy. Table 2 shows that significantly more patients received education on most general pregnancy topics compared to pelvic floor conditions. However, there was no statistical difference in the numbers receiving information on Kegels or urinary incontinence compared to ruptured membranes, where the confidence intervals overlap (Table 2). In certain instances, there were differences in the rates of information provided to white versus African American patients. Table 3 displays these differences. There was no clear-cut pattern of differences between pelvic floor issues versus general obstetric issues.

Table 1 Sociodemographics of the group (n=232)
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Table 2 Numbers of patients receiving no information on various topics
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Table 3 Rates of information received by race
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Most patients (123/232, 53%) were unaware that pelvic floor exercises reduce the risk of urinary incontinence. Most (134/232, 57.8%) were unaware that increased weight is a risk factor for urinary incontinence. When asked whether they thought a Cesarean section could help to prevent urinary incontinence, 136/232 (58.6%) answered ‘no’, and 9 (3.9%) were ‘unsure’.

Physicians or nurses in the doctor’s office were the most likely source of information on all pregnancy topics. Significantly fewer patients received information about pelvic floor complications from their healthcare providers compared to general topics (Table 4). There was no significant difference in the amount or types of information received between those receiving prenatal care in the resident clinic compared to the private practices. We were unable to determine if there was any difference among private practitioners who have interest in urogyneclogy versus those who do not, as we had no way to quantify this and we did not know whether the physician who delivered the patient also performed the majority of the prenatal care as most practices share call within a larger pool.

Table 4 The number of patients receiving information and the reported source
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Discussion

One aspect of informed consent is adequate knowledge on the part of the person making the decision [5]. From this study, it appears that we as health care providers are reasonably good at providing information despite increasing time constraints. The majority of patients received information about general pregnancy conditions such as weight gain, preterm labor, and hypertension. These conditions are common and are routinely monitored throughout pregnancy. Patients are specifically questioned and screened for these complications at each visit. Thus the health care provider has multiple encounters throughout the pregnancy to discuss these topics, which may be the reason that patients had high recall of these specific conditions. Issues that relate to the delivery process itself i.e. episiotomy, sutures, forceps, incontinence, and vaginal changes would likely be discussed at a later stage of pregnancy and less frequently, by virtue of timing. Therefore recall may be lower or in the absence of repetition recall, may be more difficult.

The information that the patient receives may be at odds with current practice depending on ‘where’ they receive that information [6]. Our study demonstrates that most women received their counseling from a health care provider. In most categories, this occurred twice as frequently as from other sources. However, 28 – 55% did receive information from an additional source. This knowledge is important, as these sources need to be determined to be accurate.

The type of information given has been reported to influence decision-making, as is the case with VBAC. Lau et al reported that 53% of women would elect to VBAC, if told they had a 70% chance of success [7]. It has also been noted that intensive counseling can reduce the request for cesarean section in women requesting operative delivery because of fear and anxiety [8]. However women are a diverse group. In a study of English women, Green noted that only 17% opted for a cesarean section when presented with a hypothetical chance of 50% for a successful vaginal delivery [9].

It is important that balanced and unbiased information be given. This can be difficult, as in the case of urinary incontinence, as the literature has been conflicting. Pregnancy alone is a risk factor and cesarean section is not entirely protective. Rortveit and colleagues reported that women who deliver by cesarean section have higher rates of urinary incontinence than nulliparous patients but less than vaginally parous women [10]. However after the age of 50 years, there was no association with delivery type. Increased BMI is a consistently reported risk factor for both urge and stress incontinence [11]. Despite the fact that patients felt well-informed about appropriate weight gain in pregnancy, less than half were aware that excess weight is associated with an increased risk.

There is good evidence that cesarean section prior to labor is protective against anal sphincter tears, which are the leading cause of fecal incontinence in young women [12, 13]. Neuropathic injury appears to be an additional etiological factor [14]. Despite this well and consistently documented risk, 80% of patients in our study, were unaware of fecal incontinence or nerve injury as potential complications with delivery. This is a surprisingly large number when one considers that physicians cited urinary and fecal incontinence as the major reason for preferring a Cesarean delivery for themselves or their partners [1].

The development of forceps revolutionized the management of obstructed labor; however, its use in modern obstetrics is coming into question. There is little doubt that forceps are a major risk factor for anal sphincter lacerations, which is an independent risk factor for fecal incontinence [15–17]. Authors have questioned whether a patient would give informed consent if they knew these risks [16–18]. This study shows that less than 50% of our patients received any instruction on forceps, episiotomy, lacerations and less than 20% on fecal incontinence and neuropathy.

One may argue that patients may not be interested in this amount of detailed information and are more interested in risks with a high probability. There is evidence in the literature, that patients are interested in detailed and extensive disclosures [17, 19].

Limitations of the study include the fact that the questionnaires were completed on post-partum day 1. This recall bias cannot be eliminated. Performing the study at a later time would be more likely to result in greater bias. The questionnaires were given out by students not involved in the patients’ prenatal or intrapartum care-which should help to eliminate any tendency to either respond in the affirmative to please the physician or negative if the patient was unhappy with the delivery process.

Pregnancy is the ideal time for patient education, as many patients have consistent contact with health care providers and are motivated by the pregnancy itself. Unfortunately, it appears in the Midwest that counseling on common pregnancy conditions appears to be lacking for many patients. Despite the fact that physicians believe that pelvic floor complications are important for their personal delivery decisions, instruction on these risks occurs significantly less often than for most general pregnancy topics. This study provides us with the impetus to develop educational tools to help us, as physicians enhance patient knowledge. There are educational videos and pamphlets available through the American College of Obstetricians and Gynecologists on topics such as hysterectomy. Practitioners use these during pre-surgical counseling. The idea of the development of a video on the pelvic floor risks and changes associated with pregnancy and delivery, which could be viewed by patients in the waiting room, is indeed appealing. Logistically, this may be difficult in this medical-legal climate, as it could be a delicate balance between presenting the literature, for example on the risks of forceps which would challenge their use and the need for such an intervention in the case of non-reassuring fetal status. Therein lies the challenge to all educators.