Incidence and etiology of pelvic floor dysfunction and mode of delivery: an overview

Evaluating changes in the strength of the levator ani muscle after vaginal delivery using T2-parameter mapping

OBJECTIVE

To evaluate pelvic floor muscle injury in patients with levator ani muscle (LAM) weakness after vaginal delivery using T2-parameter mapping.

MATERIALS AND METHODS

40 parturients (patient group) and 25 nonparturients (healthy control group) were enrolled in the study. The LAM weakness group had a Modified Oxford Grading System (MOGS) grade of less than 3 after vaginal delivery. All participants underwent pelvic magnetic resonance imaging (MRI) scans, including T2 and T2* mapping, on which the main branches of the LAM, the puborectalis and iliococcygeus, were evaluated. The differences in T2 and T2* values in the puborectalis and iliococcygeus between patients with LAM weakness and controls were analyzed using an independent samples t test or a Mann-Whitney U test.

RESULTS

For both the right and left iliococcygeus, the T2* values of the patient group were lower than those of the control group (P = 0.002 and 0.008, respectively), while no significant difference was observed in the T2 values between the groups (P = 0.45 and 0.69, respectively). For both the right and left puborectalis, no significant differences in the T2* (P = 0.25 and P = 0.25, respectively) or T2 values (P = 0.38 and 0.43, respectively) were observed between the patient and control groups.

CONCLUSION

T2* mapping as a quantitative measurement is an effective imaging tool to assess LAM injury in women after vaginal delivery. The iliococcygeus was more susceptible to vaginal delivery damage than the puborectalis, and pelvic floor dysfunction may be mainly driven by iliococcygeus injury.

Pelvic Floor Muscle Training versus Functional Magnetic Stimulation for Stress Urinary Incontinence in Women: A Randomized Controlled Trial

BACKGROUND

There is strong evidence that specific pelvic floor muscle training (PFMT) reduces stress urinary incontinence (SUI), but the application of functional magnetic stimulation (FMS) is still under discussion.

OBJECTIVE

To evaluate and compare the effects of FMS and PFMT on pelvic floor muscle function, urinary incontinence symptoms and quality of life (QoL) in women with SUI.

METHODS

A randomized controlled, parallel-group trial was executed in an outpatient physical medicine and rehabilitation centre. The study included 68 women and was fully completed by 48 women (n = 24 in each group) aged 29-49 years, with SUI, who were randomly assigned to PFMT and FMS groups. The symptoms of urinary incontinence and their impact on quality of life were assessed with two questionnaires: the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and the Incontinence Impact Questionnaire-Short Form (IIQ-7). Perineometer (Pelvexiser) was used to measure the resting vaginal pressure, pelvic floor muscle (PFM) strength and endurance. All outcome measures were taken at baseline and after 6 weeks of interventions. Cohen's effect size (d) was calculated.

RESULTS

A significant improvement (p < 0.05) of ICIQ-SF and IIQ-7 was observed in both groups with a high effect size in the PFMT group (d = 1.56 and d = 1.17, respectively) and the FMS group (d = 1.33 and d = 1.45, respectively). ICIQ-SF and IIQ-7 scores did not differ significantly between groups after the 6-week treatment period. Resting vaginal pressure, PFM strength and endurance increased (p < 0.05) in both groups with a medium (d = 0.52) to large (d = 1.56) effect size.

CONCLUSION

No significant difference between groups was found in any measurement of perineometry. PFMT and FMS significantly improved SUI symptoms and the quality of life of the study participants. None of the applied interventions was superior to the other in the short-term effect.

Pelvic floor disorder and relevant factors in Iranian women of reproductive age: a cross-sectional study

BACKGROUND

With high severity and prevalence, pelvic floor disorder is a health issue that women face worldwide. Different demographic-obstetric factors are involved in the emergence of this dysfunction that can have many adverse effects on a woman's quality of life. Hence, this study aimed to determine the prevalence of pelvic floor disorder and its related socio-demographic and obstetric factors among Iranian women of reproductive age.

METHODS

The statistical population of this cross-sectional study included 400 woman of reproductive age (15-49 years) covered by the health centers of Tabriz, Iran in 2022. The cluster sampling method was employed to select the participants. The data collection tools were a socio-demographic and obstetric characteristics questionnaire and the PDFI-20 (Pelvic Floor Distress Inventory-20). The chi-squared test was conducted to determine the association between socio-demographic and obstetric characteristics and prevalence of pelvic floor disorder in a bivariate analysis, whereas the multivariate logistic regression test was used in a multivariate analysis.

RESULTS

The general prevalence of pelvic floor disorder was 76%. The prevalence rates of pelvic organ prolapse distress 6 (POPDI-6), colorectal-anal distress 8 (CRAD-8), and urinary distress (UDI-6) were 54.3%, 61.8%, and 49.3%, respectively. The results of the multivariate logistic regression test indicated that constipation (odds ratio = 5.62; 95% CI 1.97 to 16.03; P = 0.001) increased the risk of pelvic floor disorder.

CONCLUSIONS

According to the findings, the prevalence of pelvic floor disorder is high among Iranian women of reproductive age. This condition is correlated with constipation. Therefore, screening is recommended through valid tools in addition to offering preventive measures such as preventing and curing constipation to reduce the risk of pelvic floor disorder.

Planned mode of birth after previous cesarean section and risk of undergoing pelvic floor surgery: A Scottish population-based record linkage cohort study

BACKGROUND

The global rise in cesarean sections has led to increasing numbers of pregnant women with a history of previous cesarean section. Policy in many high-income settings supports offering these women a choice between planned elective repeat cesarean section (ERCS) or planned vaginal birth after previous cesarean (VBAC), in the absence of contraindications to VBAC. Despite the potential for this choice to affect women's subsequent risk of experiencing pelvic floor disorders, evidence on the associated effects to fully counsel women is lacking. This study investigated the association between planned mode of birth after previous cesarean section and the woman's subsequent risk of undergoing pelvic floor surgery.

METHODS AND FINDINGS

A population-based cohort study of 47,414 singleton term births in Scotland between 1983 to 1996 to women with 1 or more previous cesarean sections was conducted using linked Scottish national routine datasets. Cox regression was used to investigate the association between planned as well as actual mode of birth and women's subsequent risk of having any pelvic floor surgery and specific types of pelvic floor surgery adjusted for sociodemographic, maternal medical, and obstetric-related factors. Over a median of 22.1 years of follow-up, 1,159 (2.44%) of the study population had pelvic floor surgery. The crude incidence rate of any pelvic floor surgery per 1,000 person-years was 1.35, 95% confidence interval (CI) 1.27 to 1.43 in the overall study population, 1.75, 95% CI 1.64 to 1.86 in the planned VBAC group and 0.66, 95% CI 0.57 to 0.75 in the ERCS group. Planned VBAC compared to ERCS was associated with a greater than 2-fold increased risk of the woman undergoing any pelvic floor surgery (adjusted hazard ratio [aHR] 2.38, 95% CI 2.03 to 2.80, p < 0.001) and a 2- to 3-fold increased risk of the woman having surgery for pelvic organ prolapse or urinary incontinence (aHR 3.17, 95% CI 2.47 to 4.09, p < 0.001 and aHR 2.26, 95% CI 1.79 to 2.84, p < 0.001, respectively). Analysis by actual mode of birth showed these increased risks were only apparent in the women who actually had a VBAC, with the women who needed an in-labor non-elective repeat cesarean section having a comparable risk of pelvic floor surgery to those who had an ERCS. The main limitation of this study is the potential for misclassification bias.

CONCLUSIONS

This study suggests that among women with previous cesarean section giving birth to a singleton at term, planned VBAC compared to ERCS is associated with an increased risk of the woman subsequently undergoing pelvic floor surgery including surgery for pelvic organ prolapse and urinary incontinence. However, these risks appear to be only apparent in women who actually give birth vaginally as planned, highlighting the role of vaginal birth rather than labor in pelvic floor dysfunction requiring surgery. The findings provide useful additional information to counsel women with previous cesarean section about the risks and benefits associated with their future birth choices.

The establishment of a 3D anatomical coordinate system for defining vaginal axis and spatial position

BACKGROUND AND OBJECTIVE

Pelvic organ prolapse (POP), the herniation of the pelvic organs toward the vaginal opening, is a common pelvic floor disorder (PFD) whose etiology is poorly understood. Traditional methods for evaluating POP are often constrained to external vaginal examination, limited to 2D, or have poor reproducibility. We propose a reliable 3D anatomic coordinate system for standardized 3D assessment of pelvic anatomy using magnetic resonance imaging (MRI).

METHODS

The novel 3D anatomic reference system is based on six bony landmarks of the pelvis manually identified in MRI: the ischial spines and the superior and inferior pubic points of the left and right pubic symphysis. The origin of this system is defined as the midpoint of the ischial spines. The reproducibility and applicability of the pelvic coordinate system were evaluated by (1) implementing it in a new method to quantify vaginal position and axis (angulation) in 3D space from MRI segmentations of the vagina and (2) computing the intraclass correlation (ICC) on coordinate system and vaginal measures. The MRI analysis was performed by four non-medically trained observers on five pelvic MRI datasets on approximately five separate occasions.

RESULTS

Overall, all bony landmarks had excellent intra-observer reliability and inter-observer reliability (ICC>0.90); intra-observer reliability was moderate-to-good among the vaginal position parameters (0.5

CONCLUSIONS

The proposed anatomic coordinate system and vaginal analysis approach allow quantitative assessment of pelvic anatomy that is robust to the experience level of the observer. The application of these methods in radiographic studies will give new insight into the underlying anatomic changes involved in the pathogenesis of POP and other PFDs and help better understand their etiology.

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Key Words

• 3D Coordinate System
• MRI
• Pelvic Organ Prolapse
• Pelvis
• Reliability Analysis
• Vagina

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MESH Headings

• Female
• Humans
• Magnetic Resonance Imaging
• Pelvic Organ Prolapse
• Pelvis
• Reproducibility of Results
• Vagina/diagnostic imaging

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Grants

• UG1 HD069006 NICHD NIH HHS

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Affiliation(s)

Deanna C E Sinex Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
Shaniel T Bowen Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
Ahmed Kashkoush Cleveland Clinic Foundation, Cleveland, OH, United States
Arianna Rosemond 4350 Northern Pike #150, Monroeville, PA, United States
Danielle Carter Silver Spring, MD, United States
Prahlad G Menon Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
Pamela A Moalli Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States; Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh Medical Center, Magee Women's Research Institute, Pittsburgh, PA, United States
Steven D Abramowitch Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States.

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Prolonged second stage effect on pelvic floor dysfunction: a follow up survey to a randomized controlled trial

BACKGROUND

Pelvic floor dysfunction is a group of disorders that can significantly impact quality of life due to persistent urinary and anal incontinence. Data evaluating the effect of prolonged second stage of labor and postpartum pelvic floor dysfunction is heterogenous and limited.

OBJECTIVE

To evaluate whether extending the length of labor in nulliparous women with prolonged second stage affects the presence of self-reported pelvic floor dysfunction after a randomized controlled trial of prolonged second stage.

STUDY DESIGN

We conducted a planned follow up survey to our randomized controlled trial of prolonged second stage of labor using the Pelvic Floor Distress Inventory-20 (PFDI-20). The primary outcome was the PFDI-20 summary score. Secondary outcomes included urinary and fecal incontinence, prolapse, and patient satisfaction. Women surveyed were nulliparous patients with epidural anesthesia, previously enrolled in a randomized controlled trial that assigned them to extended labor, at least 1 additional hour in the second stage if they were undelivered after three hours, or to usual labor, defined as expedited delivery after three hours in the second stage. Women were surveyed at 12 - 36 months postpartum.

RESULTS

Thirty-four of the seventy-eight women responded to the survey (43.6%). 17 women (50.0%) were from the extended labor group and 17 from the usual labor group (50.0%). Maternal demographic data were not significantly different between groups. The PFDI-20 summary score was 13.8 ± 23.3 in the extended labor group and 13.1 ± 20.9 in the usual labor group (p = 0.9). The Pelvic Organ Prolapse Distress Inventory-6 was 1.2 ± 2.9 in the extended labor group and 2.7 ± 6.4 in the usual labor group (p = 0.4). The Colorectal-Anal Distress Inventory-8 was 0.8 ± 2.8 in the extended labor group and 2.1 ± 4.0 in the usual labor group (p = 0.6). The Urinary Distress Inventory-6 was 11.8 ± 21.1 in the extended labor group and 8.3 ± 14.5 in the usual labor group (p = 0.6). Maternal and neonatal outcomes, as well as patient satisfaction, were not statistically significantly different between groups.

CONCLUSION

Extending the length of labor in nulliparas with singleton gestations, epidural anesthesia, and prolonged second stage did not have an impact on PFDI-20 scores at 12-36 months postpartum. However, our study was underpowered to detect small, but potentially clinically important, differences.

CLINICAL TRIAL NUMBER

NCT02101515 (Study Registration Date March 28, 2014) https://clinicaltrials.gov/ct2/show/NCT02101515.

Impact of pelvic floor ultrasound in diagnosis of postpartum pelvic floor dysfunction: A protocol of systematic review

BACKGROUND

This study will appraise the impact of pelvic floor ultrasound (PFU) in diagnosis of postpartum pelvic floor dysfunction (PPPFD).

METHODS

Studies that report the impact of PFU in diagnosis of PPPFD will be examined in Cochrane Library, MEDLINE, EMBASE, PSYCINFO, Scopus, Web of Science, Allied and Complementary Medicine Database, CNKI, and WANGFANG up to June 1, 2020. Grey literature sources will also be searched. All potential case-controlled studies (CCSs) exploring the impact of PFU in diagnosis of PPPFD will be considered for inclusion in this study. Data will be extracted from eligible CCSs for data pooling and meta-analysis. Whenever necessary, we will also perform summary effect size, heterogeneity across studies, study quality assessment, and reporting bias.

RESULTS

The present study will estimate pooled outcome effects regarding the impact of PFU in diagnosis of PPPFD.

CONCLUSION

This study may provide robust evidence to judge the impact of PFU on PPPFD SYSTEMATIC REVIEW REGISTRATION:: PROSPERO CRD42020187623.

Clinical Significance of Neuropeptide Y Expression in Pelvic Tissue in Patients with Pelvic Floor Dysfunction

OBJECTIVES

To investigate the neuropeptide Y (NPY) expression in the tissue of pelvic floor ligament and anterior vaginal wall in female patients with pelvic organ prolapse (POP) and stress urinary incontinence (SUI).

METHOD

Seventeen patients with POP, 6 with SUI, 13 with POP and SUI (POP&SUI), and 10 controls were included in this study from First Affiliated Hospital of JiNan University. Immunohistochemical assay was used to examine NPY expression in the tissue of round ligament, cardinal ligament of uterus, uterosacral ligament, and anterior vaginal wall. NPY expression were compared between POP, SUI, POP&SUI and controls.

RESULTS

NPY was positive expressed in the round ligament, cardinal ligament of uterus, uterosacral ligament, and anterior vaginal subepithelial connective tissue. Compared with the control group, NPY expression in the round, cardinal, and uterosacral ligaments in patients with POP&SUI group was decreased with significant statistical difference (p<0.05). NPY expression in anterior vaginal wall was significantly decreased in POP, SUI, and POP&SUI groups compared to normal group (p<0.05). Compared to POP group, NPY expression in SUI and POP&SUI groups were significantly decreased (p<0.05), however the difference was not statistical different between SUI and POP&SUI groups (p>0.05). In POP and POP&SUI groups, the NPY expression in the cardinal ligament of uterus, uterosacral ligament, and anterior vaginal wall were negatively correlated with age (p<0.05), however, was not correlated with number of pregnancy, number of delivery, and BMI (p>0.05).

CONCLUSIONS

NPY expression was reduced in the round ligament, cardinal ligament of uterus, Uterosacral ligament, and vaginal anterior wall of the patients with POP and SUI. The decreased NPY expression may play an important role in the development of pelvic floordysfunction.

Obstructed Defecation Syndrome After Delivery Trauma

Background:

Obstructed defecation syndrome (ODS) occurs in about 7% of adults; it seems that the etiology of pelvic floor disorders is multifactorial. Pregnancy and childbirth damage to the pelvic nerve and muscles are proposed causes for this condition. The precise role of vaginal delivery (VD) is not clearly defined, although in recent studies association of pelvic floor disorder with Operative vaginal delivery and episiotomy has been proposed.

Objectives:

In this prospective study, we assessed the outcome of stapled transanal rectal resection (STARR) in females with one of the two modes of delivery (VD or caesarean section (C/S).

Patients and Methods:

We used Longo’s ODS score for the assessment of the severity of pelvic floor malfunction. Stapled Trans Anal Rectal Resection (STARR) procedure was performed using two circular staplers. Follow-up was done 12 months after the discharge. To assess the role of episiotomy in patient with VD, we divided them into two subgroups; females who had VD with episiotomy (Vd + epi) and females who had VD alone. Data were analyzed using SPSS version 20 software. P values less than 0.05 were considered statistically significant.

Results:

In 30 consecutive females undergoing STARR for the treatment of ODS, who enrolled in this prospective study, 19 (63.3%) had Vaginal Delivery VD and 11 (36.7%) had Cesarean Section (C/S). The ODS score before the surgery was higher in females who had C/S, although there was no significant difference between VD and C/S groups in terms of the percentage of the ODS score improvement after the STARR surgery.

Conclusions:

Higher ODS score in females who had C/S showed that C/S could not protect the pelvic organ from pregnancy and delivery trauma. It seems that episiotomy has a protective effect during VD; it can reduce the severity of trauma in pelvic organs during childbearing.

Prevalence of Fecal Incontinence in Women During Pregnancy: A Large Cross-Sectional Study

BACKGROUND

Although some studies have analyzed the prevalence of urinary incontinence during pregnancy, there are scarce data on the frequency and characteristics of fecal incontinence during this period.

OBJECTIVE

The aim of this study was to determine the incidence and characteristics of women with fecal incontinence symptoms during early and late pregnancy, to evaluate its impact on quality of life, and to identify whether there is a specific clinical pattern that could identify patients at risk.

DESIGN

This was a cross-sectional observational study.

SETTINGS

The study was conducted at the maternity unit of a university tertiary care center.

PATIENTS

Pregnant women undergoing obstetric follow-up were included in the study.

MAIN OUTCOME MEASURES

A prospective study was conducted. All of the patients attending our maternity unit for obstetric ultrasound examination during the first and third trimesters were eligible for inclusion. Selected patients completed a self-reported questionnaire that included items on fecal incontinence, Wexner score, and stool consistency. Quality of life was assessed using the Medical Outcomes Study Short Form 36.

RESULTS

The study included 228 consecutive pregnant women. Ninety-three patients (40.8%) had some episode of fecal incontinence in the 4 weeks before the survey, 15 patients with solid stool, 6 patients with liquid stools, and 72 with flatus. In these patients, the mean Wexner score was 3.82 (range, 2.0-13.0). In patients with incontinence, quality of life was significantly affected in most subscales of Medical Outcomes Study Short Form 36. There were no significant differences in the following variables between patients with and without symptoms of fecal incontinence, including age (p = 0.090), BMI (p = 0.094), history of previous deliveries (p = 0.492), trimester of pregnancy (p = 0.361), and Bristol Stool Form Scale (p = 0.388).

LIMITATIONS

The cross-sectional design hampered identification of specific time at which the impact of pregnancy occurred.

CONCLUSIONS

The prevalence of fecal incontinence is high during pregnancy with a notable impact on quality of life. There was no specific clinical pattern during pregnancy that could define patients at risk for fecal incontinence during this period of life.

A descriptive analysis of the indications for caesarean section in mainland China

Background

In recent decades we have observed a remarkable increase in the rate of caesarean section (CS) in both developed and developing countries, especially in China. However, the real reasons for this phenomenon are uncertain. Notably, the number of women requesting elective CS without accepted valid medical indication has also increased, generating a nationwide debate because several studies have shown that this may be the underlying cause of the increase in CS rates observed recently. Therefore, we carried out a multicentre, large-sample, cross-sectional study to describe the CS rate and indications for CS in mainland China during 2011.

Methods

This was a multicentre, large-sample, cross-sectional study of women who delivered infants in 39 hospitals in 14 provinces in China during 2011. We selected 111, 315 deliveries that occurred during 2011, excluding miscarriages or termination of pregnancy before 28 gestational weeks.

Results

The overall rate of CS in mainland China was 54.90%. The most common indication for CS was caesarean delivery on maternal request (CDMR; 28.43%), followed by cephalo-pelvic disproportion (14.08%), fetal distress (12.46%), previous CS (10.25%), malpresentation and breech presentation (6.56%), macrosomia (6.10%) and other indications (22.12%). CDMR accounted for 15.53% of all the deliveries and 28.43% of all CS deliveries in mainland China.

Conclusions

CDMR appears to be a considerable driver behind the increasing CS rate in mainland China. The relaxation of China’s “one-child policy” may translate into a greater number of CS because of previous CS delivery. To decrease the CS rate, we should first decrease the rate of CS on maternal request. Appropriate policies and guidelines should be considered to accomplish the goal.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-014-0410-2) contains supplementary material, which is available to authorized users.

A Comparison of Vaginal Pressures and Abdominal Muscle Thickness According to Childbirth Delivery Method during the Valsalva Maneuver

[Purpose] The purpose of this study was to compare the effect of childbirth delivery method on vaginal pressure and abdominal thickness during the Valsalva maneuver (VAL). [Subjects] Thirty healthy female volunteers (26-39 years of age) were selected for this research. Their delivery histories were: nulliparous 10, vaginal delivery 10, and Cesarean delivery 10. None of the participants had a history of incontinence. [Methods] In the crook-lying position, a perineometer probe was inserted into the vagina and the transducer was placed transversely on the right side of the body during the Valsalva maneuver. [Results] There were significant differences in the thickness of the transverses abdominis (TrA) between in all the groups rest and the Valsalva maneuver, and there were significant differences in the internus oblique (IO) in the nulliparous group. During the Valsalva maneuver, there were significant differences in the TrA between the nulliparous group and the vaginal delivery group, and there were significant differences in the IO between the nulliparous delivery group and the vaginal delivery group, and between the nulliparous group and the Cesarean section group. Delivery history changed vaginal pressure, and there were significant differences between the nulliparous group and the vaginal delivery group, and between the nulliparous group and the Cesarean delivery group. [Conclusion] Pregnancy and delivery method may affect pelvic floor and abdominal muscles during the Valsalva maneuver.

Racial differences in fecal incontinence in community-dwelling women from the EPI study

OBJECTIVES

Despite its prevalence and associated distress, fecal incontinence (FI) is not well understood. There are limited data regarding associations between FI and race. The goal of this study was to estimate the prevalence of FI, and to secondarily identify demographic, lifestyle, and medical factors associated with FI, especially with regard to race.

METHODS

This was a planned secondary analysis of a population-based cross-sectional telephone interview survey of 2812 black and white community-dwelling women living in southeastern Michigan. The primary outcome measured was the prevalence of self-reported FI, defined as any loss of stool during the previous 12 months. Logistic regression modeling was used to identify characteristics independently associated with FI.

RESULTS

Of the subjects, 16.7% reported FI in the previous year. Fecal incontinence was approximately twice as common in white women (20%) as black women (11%). Factors associated with FI differed between the 2 races, although its prevalence in both racial groups increases with higher numbers of medical comorbidities, increased frequency of bowel movements per week, and depression.

CONCLUSIONS

One in 6 women report FI, although it occurs one-half as often in black as in white women. Although there are common characteristics shared by women with FI in both racial groups, white women experience FI in complex with other pelvic floor disorders. For black women, FI is an isolated pelvic floor disorder associated with mobility impairment.

Impact of childbirth and mode of delivery on vaginal resting pressure and on pelvic floor muscle strength and endurance

OBJECTIVE

We sought to study impact of delivery mode on vaginal resting pressure (VRP) and on pelvic floor muscle (PFM) strength and endurance, and whether these measurements differed in women with and without urinary incontinence.

STUDY DESIGN

We conducted a cohort study following 277 nulliparous women from midpregnancy to 6 weeks postpartum. Manometer was used for PFM measurements; differences were analyzed by t test (within groups) and analysis of variance (between groups).

RESULTS

Only VRP changed significantly (10% reduction, P = .001) after emergency cesarean section. After normal and instrumental vaginal delivery, VRP was reduced by 29% and 30%; PFM strength by 54% and 66%; and endurance by 53% and 65%, respectively. Significant differences for all PFM measures (P < .001) were found when comparing cesarean vs normal and instrumental vaginal delivery, respectively. Urinary continent women at both time points had significantly higher PFM strength and endurance than incontinent counterparts (P < .05).

CONCLUSION

Pronounced reductions in VRP and in PFM strength and endurance were found after vaginal delivery. Continent women were stronger than incontinent counterparts.

Prevention of Labour-Associated Pelvic Floor Injuries - What is Known for Sure

In order to avoid pelvic floor injuries a caesarean section is on the one hand often requested by the pregnant women and, on the other hand, offered by obstetric staff. For both forms of delivery, comprehensive risk-benefit analyses should be carried out before deciding in favour of the surgical procedure. The present brief review summarizes the current evidence on the avoidance of pelvic floor injuries.

Strength of round and uterosacral ligaments: a biomechanical study

PURPOSE

To investigate the tensile biomechanical properties of round and uterosacral ligaments.

METHODS

Tissue samples were obtained from 15 female cadavers without pelvic organ prolapse. Uniaxial tensile tests were performed to obtain stiffness and maximum stress of round and uterosacral ligaments. Correlations were calculated using the Pearson correlation coefficient. Statistical differences between groups were tested using Student's paired and unpaired t test.

RESULTS

There was a great variability in the measurements of stiffness and maximum stress in pelvic ligaments. The round ligaments demonstrated stiffness of 9.1 ± 1.6 MPa (mean ± SEM) (ranging from 2 to 25.6 MPa) and maximum stress of 4.3 ± 0.7 MPa (ranging from 1.2 to 11.5 MPa). The stiffness of the uterosacral ligaments was 14.1 ± 1.4 MPa (ranging from 5.7 to 26.1 MPa) with maximum stress of 6.3 ± 0.8 MPa (ranging from 2.2 to 11.9 MPa). There was a strong positive correlation between stiffness and maximum stress in female pelvic ligaments (ρ = 0.851; p < 0.001). The uterosacral ligaments demonstrated higher stiffness and maximum stress compared to the round ligaments (p = 0.006 and p = 0.034; respectively). Age, body mass index and menopausal status were not associated with the biomechanical proprieties of round and uterosacral ligaments. Nulliparous women had lower uterosacral stiffness (15.5 ± 1.3 vs. 10 ± 1.8 MPa; p = 0.033) and maximum stress (8.2 ± 0.9 vs. 4.2 ± 1.1 MPa; p = 0.028) compared to parous women.

CONCLUSION

The uterosacral ligaments are significantly more resistant than round ligaments. Parturition seems to enhance the stiffness and maximum stress of the ligaments.

Pelvic organ distribution of mesenchymal stem cells injected intravenously after simulated childbirth injury in female rats

The local route of stem cell administration utilized presently in clinical trials for stress incontinence may not take full advantage of the capabilities of these cells. The goal of this study was to evaluate if intravenously injected mesenchymal stem cells (MSCs) home to pelvic organs after simulated childbirth injury in a rat model. Female rats underwent either vaginal distension (VD) or sham VD. All rats received 2 million GFP-labeled MSCs intravenously 1 hour after injury. Four or 10 days later pelvic organs and muscles were imaged for visualization of GFP-positive cells. Significantly more MSCs home to the urethra, vagina, rectum, and levator ani muscle 4 days after VD than after sham VD. MSCs were present 10 days after injection but GFP intensity had decreased. This study provides basic science evidence that intravenous administration of MSCs could provide an effective route for cell-based therapy to facilitate repair after injury and treat stress incontinence.

Perinatal urinary and fecal incontinence: suffering in silence

This article focuses on the prevention, identification, and management of urinary and fecal incontinence in the perinatal period. Both urinary and fecal incontinence are common concerns affecting women throughout pregnancy, intrapartum, and postpartum. These are the problems that are not approached by healthcare providers during the initial antepartal assessment, nor are they fully investigated after delivery. Many women hesitate to disclose this information. Women tend to consider this to be a minor discomfort of pregnancy and a consequence resulting from childbirth in the postpartum period. Intervention strategies and nursing care components in the perinatal period will be presented.

Computational modeling approach to study the effects of fetal head flexion during vaginal delivery

OBJECTIVE

The purpose of this study was to investigate the influence of fetal head flexion during vaginal delivery with a 3-dimensional computational finite element model.

STUDY DESIGN

A finite element model of the pelvic skeletal structure, pelvic floor, and fetus was developed. The movements of the fetus during birth were simulated in engagement, descent, flexion, internal rotation, and extension of the fetal head. The opposite forces against the fetal descendent and the stress of the pelvic floor muscles were obtained on simulations with different degrees of head flexion.

RESULTS

The simulated increase in fetal head flexion is associated with lower values of opposite forces against the fetal descent. The descending fetus with abnormal head flexion also meets resistance in later stations. Lower stress on the pelvic floor was demonstrated with simulated increase in fetal head flexion during vaginal delivery.

CONCLUSION

This analytic evidence suggests that the fetal head flexion during vaginal delivery may facilitate birth and protect the pelvic floor.