The impact of vaginal delivery on pelvic floor function - delivery as a time point for secondary prevention

Effects of Labor Analgesia on Pelvic Floor Function at 6 to 8 Weeks after Delivery: A Prospective Cohort Study

OBJECTIVE

The aim of the study is to determine whether the use of labor analgesia had a higher risk of pelvic floor functional problems after delivery.

STUDY DESIGN

All primiparas who delivered at our hospital between June 2019 and May 2020 were enrolled in the study. They were divided into two groups according to their choices: delivery with labor analgesia (analgesia group, n = 76), and delivery without labor analgesia (nonanalgesia group, n = 78). The primary outcome of the study was to test the pelvic floor function by electromyography (EMG) at postpartum 6 to 8 weeks. Participants also completed questionnaires including Pelvic Floor Distress Inventory (PFDI-20), International Consultation on Incontinent Questionnaire-Short Form (ICIQ-SF), and Overactive Bladder Symptom Score (OABSS) at postpartum 6 to 8 weeks.

RESULTS

Primiparas in the analgesia group experienced longer first and second stages of labor (p< 0.05), and had significantly higher PFDI-20 scores at postpartum 6 to 8 weeks (p< 0.05). But the differences in ICIQ-SF, OABSS scores, and Pelvic Organ Prolapse Quantification (POP-Q) system between the two groups were not significant (p > 0.05). No statistically significant difference was found in class II and class I muscles, scores of pretest resting baseline, and posttest resting baseline between primiparas with or without labor analgesia (p > 0.05).

CONCLUSION

Our results strongly confirmed that labor analgesia did not increase the risk of pelvic floor dysfunction up to 6 to 8 weeks after delivery, although symptom burden might be increased after labor analgesia.

KEY POINTS

· Labor analgesia did not increase risk of pelvic floor muscle dysfunction after delivery.. · There are longer first and second stages of labor in primiparas with labor analgesia.. · Primiparas with labor analgesia had more obvious subjective symptoms of PFD..

Correlates of health-seeking behavior for sexual dysfunction after childbirth: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

Persistent sexual dysfunction (SD) after childbirth is common, but many patients do not receive adequate care, for unknown reasons. The aim of this study is to examine correlates for health care-seeking behavior for SD within 3 years after birth.

METHODS

Subjects filled out an electronic survey regarding sexual function, obstetric, relationship, and demographic characteristics. The Sexual Function Questionnaire's Medical Impact Scale) as well as a number of novel, targeted survey questions were used to measure the impact of childbirth on sexual function. Patients were stratified into those without SD, and those with SD, both seeking and not seeking care. These domains were then compared in a series of univariate, bivariate, and multivariate analyses.

RESULTS

Of 531 patients who completed the survey, 449 women (84.5%) reported some form of SD after birth. Only 16.0% of those with SD sought care for SD. Variables associated with care seeking include difficulty with perineal healing (adjusted odds ratio [aOR]=4.53, 95% confidence interval [CI]: 1.54-13.38), transfusion after birth (aOR=3.71, 95% CI: 1.44-9.56), current dyspareunia (aOR=3.41, 95% CI: 1.31-8.87). Factors associated with decreased probability of seeking care include children under 18 years in the home (aOR=0.61 per child, 95% CI: 0.43-0.88), number of cesarean births (aOR=0.46 per delivery, 95% CI: 0.29-0.74).

CONCLUSIONS

This study highlights that many more women suffer from SD after childbirth than seek care, and identified several important risk factors associated with decreased care seeking. Future work should focus on decreasing the difficulty of accessing care for SD after childbirth.

Predictors for sexual dysfunction in the first year postpartum: a systematic review and meta-analysis

BACKGROUND

Pregnancy and childbirth increase the risk for pelvic floor dysfunction, including sexual dysfunction. So far, the mechanisms and the extent to which certain risk factors play a role remain unclear.

OBJECTIVES

In this systematic review of the literature we aimed to determine risk factors for sexual dysfunction in the first year after childbirth.

SEARCH STRATEGY

We searched MEDLINE, Embase and CENTRAL using the search strategy: sexual dysfunction AND obstetric events.

SELECTION CRITERIA

We included original, comparative studies, reported in English, that used validated questionnaires and the ICS/IUGA terminology for sexual dysfunction, dyspareunia and vaginal dryness.

DATA COLLECTION AND ANALYSIS

We assessed the quality and the risk of bias of the included studies with the Newcastle-Ottawa scale. We extracted the reported data and we performed random-effects meta-analysis to obtain the summary odds ratios (ORs) with 95% confidence intervals (95% CIs). Heterogeneity across studies was assessed using the I² statistic.

MAIN RESULTS

Anal sphincter injury was associated with increased odds for both sexual dysfunction (OR 3.00, 95%CI 1.28-7.03) and dyspareunia (OR 1.92, 95% CI 1.47-2.52). Episiotomy was associated with dyspareunia (OR 1.64, 95% CI 1.25-2.14), but not with sexual dysfunction (OR 1.90, 95% CI 0.94-3.84). Compared with spontaneous birth, caesarean section reduced the odds for dyspareunia (OR 0.68, 95% CI 0.54-0.86) but not for sexual dysfunction (OR 1.14, 95% CI 0.89-1.46). Instrumental vaginal birth increased the odds for sexual dysfunction (OR 1.70, 95% CI 1.05-2.76), yet no difference was found for dyspareunia (OR 1.82, 95% CI 0.88-3.75). One study of low quality reported on vaginal dryness and found no association with obstetric events.

CONCLUSIONS

Perineal trauma, rather than mode of birth, increases the odds for sexual dysfunction in the first year after childbirth.

TWEETABLE ABSTRACT

Perineal trauma, rather than mode of birth, correlates with sexual dysfunction and dyspareunia postpartum. #dyspareunia #OASI #episiotomy.

Effect of Epidural Analgesia on Pelvic Floor Dysfunction at 6 Months Postpartum in Primiparous Women: A Prospective Cohort Study

INTRODUCTION

Epidural analgesia has become a universal intervention for relieving labor pain, and its effect on the pelvic floor is controversial.

AIM

To investigate the effect of epidural analgesia on pelvic floor dysfunction (PFD) in primiparous women at 6 months postpartum.

METHODS

We performed a prospective cohort study involving 150 primiparous women in preparation for vaginal delivery, with 74 (49.3%) receiving epidural analgesia. Baseline demographic and intrapartum data were collected. At 6 months postpartum, PFD symptoms, including stress urinary incontinence, overactive bladder, defecation disorder, pelvic organ prolapse, and 4 kinds of sexual dysfunction (arousal disorder, low sexual desire, dyspareunia, and orgasm disorder), were evaluated. Pelvic floor muscle (PFM) function and postpartum depression were also assessed. Multivariate logistic regression was applied to identify factors associated with the PFD symptoms affected by epidural analgesia.

MAIN OUTCOME MEASURE

PFD symptoms and sexual dysfunction were evaluated through Pelvic Floor Distress Inventory-20 (PFDI-20) and Female Sexual Function Index (FSFI-12). PFM function was examined with palpation and surface electromyography (sEMG). Postpartum depression was assessed using Self-Rating Depression Scale (SDS).

RESULTS

At 6 months postpartum, women who delivered with epidural analgesia had a higher incidence of dyspareunia (43.2% vs 26.3%, P <0.05) and longer first, second, and total stage of labor durations (P <0.01) than those who without. No significant difference in other PFD symptoms or PFM function was found between the 2 groups (P >0.05). Multivariate logistic regression revealed that epidural analgesia (OR = 3.056, 95% CI = 1.217-7.671) and SDS scores (OR = 1.066, 95% CI = 1.009-1.127) were independent risk factors for dyspareunia.

CONCLUSION

At 6 months postpartum in primiparous women, epidural analgesia was associated with an increased risk of postpartum dyspareunia and longer labor durations, which deserves attention for rehabilitation after delivery. Future studies with a larger sample size are needed to evaluate the impact of epidural analgesia on other PFD symptoms. Du J, Ye J, Fei H, et al. Effect of Epidural Analgesia on Pelvic Floor Dysfunction at 6 Months Postpartum in Primiparous Women: A Prospective Cohort Study. Sex Med 2021;9:100417.

Predicting the mechanical response of the vaginal wall in ball burst tests based on histology

A histologically motivated (HM) coefficient that establishes a link between tissue's microstructure and material model through histological data is used in the prediction of the mechanical properties of vaginal tissue that is subjected to multiaxial loading conditions. Therefore, the material parameters were based on an HM coefficient obtained from tensile testing and histological data of comparable tissues. Uniaxial tensile test data and histological data were collected from three groups of sheep at different time points in their life cycle, including virgins, pregnant, and parous ewes. From this data, a correlation between material parameters and histological data was obtained. Spherical indentation (ball burst [BB]) tests were then performed in specimens with similar tissue structure. The histological data of these samples were used in conjunction with the correlations already established for the uniaxial samples data, to define the material parameters of the BB samples. Mechanical properties of the BB specimens were predicted through basic histology and using finite element modeling (FEM) simulations, without direct mechanical measurements. The predicted force and displacement values of the FEM simulation displayed a good correlation with the experimental (BB) testing results. No fitting of the BB results was performed. In this way, the use of uniaxial tests coupled with useful histological information offers a promising approach to predicting macroscopic material behavior under multiaxial loading conditions in biomechanics.

The effect of the first vaginal birth on pelvic floor anatomy and dysfunction

Introduction and hypothesis

First vaginal delivery severely interferes with pelvic floor anatomy and function. This study determines maternal and pregnancy-related risk factors for pelvic floor dysfunction (PFD), including urinary incontinence (UI), urgency, anal incontinence (AI), pelvic organ prolapse (POP) and levator ani muscle (LAM) avulsion.

Methods

This is a single-centre prospective observational cohort study on healthy women in their first singleton pregnancy. All underwent clinical and 3D transperineal ultrasound examination at 6 weeks and 12 months postpartum. Objective outcomes were POP-Q and presence or absence of LAM trauma. Functional outcomes were measured by the ICIQ-SF and PISQ 12. Multivariate regression was performed to determine birth and maternal habitus-related risk factors for UI, urgency, AI, dyspareunia, LAM avulsion and ballooning.

Results

Nine hundred eighty-seven women were included. Risk factors for UI were maternal age per year of age (OR: 1.09; 95% CI: 1.04–1.13; p = 0.0001) and BMI before pregnancy (OR: 1.08; 95% CI: 1.04–1.13; p = 0.001); for POP stage II+ maternal age (OR: 1.08; 95% CI: 1.08–1.14; p = 0.005). Avulsion was more likely after forceps (OR: 3.22; 95% CI:1.54–8.22; p = 0.015) but less likely after epidural analgesia (OR: 0.58; 95% CI: 0.37–0.90; p = 0.015) and grade I perineal rupture (OR: 0.50; 95% CI: 0.29–0.85; p = 0.012). Ballooning was more likely at increased maternal age (OR: 1.08; 95% CI: 1.02–1.13; p = 0.005), epidural (OR: 1.64; 95% CI: 1.06–2.55; p = 0.027) and grade I perineal rupture (OR: 1.79; 95% CI: 1.10–2.90; p = 0.018).

Conclusion

Though maternal characteristics at birth such as age or BMI increase the risk of PFD, labour and birth factors play a similarly important role. The most critical risk factor for MLA avulsion was forceps delivery, while an epidural had a protective effect.

Electronic supplementary material

The online version of this article (10.1007/s00192-019-04044-2) contains supplementary material, which is available to authorized users.

Recovery of puborectalis muscle after vaginal delivery: an ultrasound study

OBJECTIVES

To assess change in levator hiatal dimensions between pregnancy and different timepoints after vaginal delivery, and map recovery of the hiatus in order to contribute to secondary prevention of symptoms of pelvic floor disorders.

METHODS

Twenty nulliparous women with a singleton pregnancy underwent ultrasound assessment of the pelvic floor at rest, on maximum pelvic floor muscle contraction (PFMC) and on Valsalva maneuver at 12 weeks' gestation and at 1 day and 1, 2, 3, 4, 6, 12, 18 and 24 weeks after vaginal delivery. Dimensions of the levator hiatus were measured and contractility and distensibility were calculated. The Wilcoxon signed rank test was used to compare each postpartum value with that at 12 weeks' gestation.

RESULTS

Levator hiatal area at rest, on PFMC and on Valsalva maneuver was significantly increased at 1 day and at 1 and 2 weeks after vaginal delivery compared with measurements at 12 weeks' gestation. Hiatal area at rest and on PFMC from 3 weeks postpartum onward, as well as contractility from 6 weeks onward, were comparable to values at 12 weeks' gestation, whereas, a significant difference remained on Valsalva maneuver until 24 weeks after delivery. Moreover, distensibility was still increased at 24 weeks postpartum compared with measurements at 12 weeks' gestation.

CONCLUSION

The puborectalis muscle has the ability to recover anatomically from a first vaginal delivery, and recovery occurs mainly during the first 3 weeks after delivery. Stretching of the puborectalis muscle, as reflected by distensibility, persisted 24 weeks after the first vaginal delivery. The data provide a better understanding of the early 'normal' regeneration process and we hypothesize that the first 3 weeks postpartum is the best window in which to start secondary prevention. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Cell-based secondary prevention of childbirth-induced pelvic floor trauma

With advancing population age, pelvic-floor dysfunction (PFD) will affect an increasing number of women. Many of these women wish to maintain active lifestyles, indicating an urgent need for effective strategies to treat or, preferably, prevent the occurrence of PFD. Childbirth and pregnancy have both long been recognized as crucial contributing factors in the pathophysiology of PFD. Vaginal delivery of a child is a serious traumatic event, causing anatomical and functional changes in the pelvic floor. Similar changes to those experienced during childbirth can be found in symptomatic women, often many years after delivery. Thus, women with such PFD symptoms might have incompletely recovered from the trauma caused by vaginal delivery. This hypothesis creates the possibility that preventive measures can be initiated around the time of delivery. Secondary prevention has been shown to be beneficial in patients with many other chronic conditions. The current general consensus is that clinicians should aim to minimize the extent of damage during delivery, and aim to optimize healing processes after delivery, therefore preventing later dysfunction. A substantial amount of research investigating the potential of stem-cell injections as a therapeutic strategy for achieving this purpose is currently ongoing. Data from small animal models have demonstrated positive effects of mesenchymal stem-cell injections on the healing process following simulated vaginal birth injury.