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Temtanakitpaisan T, Bunyavejchevin S, Buppasiri P, Chongsomchai C. Levator Ani Muscle Avulsion After Vaginal Delivery Comparing Routine Versus Restrictive Episiotomy: A Pilot Study. Int Urogynecol J 2024:10.1007/s00192-024-05883-4. [PMID: 39105747 DOI: 10.1007/s00192-024-05883-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 07/08/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to compare the rate of levator ani muscle avulsion following vaginal birth after routine and restrictive episiotomy. METHODS This study consists of two cohorts of pregnant women prospectively enrolled between September 2015 and December 2017 at a university hospital. The pregnant women were subject to a randomized controlled trial, in which participants received a restrictive episiotomy protocol versus a routine episiotomy protocol for vaginal delivery. Levator ani avulsion was evaluated by four-dimensional ultrasound screening. RESULTS Sixty-one post-partum primipara women were enrolled in our study. Thirty-two women (52.5%) had undergone routine episiotomy whereas 29 women (47.5%) had gone through restrictive episiotomy. Right mediolateral episiotomies were performed in all cases. The rate of anal sphincter tear was 12.5% in the routine episiotomy group versus 13.8% in the restrictive episiotomy group (p = 1.00). Levator ani avulsion was detected in 9.4% of the routine episiotomy group (only on the right side) and in 10.3% of the restrictive episiotomy group (p = 1.00). No bilateral levator avulsion was detected in either of the groups. There were no statistical differences in the distances of the bladder neck descent, cystocele descent, uterine descent, rectocele descent, and the ballooning of the genital hiatus area between the groups. CONCLUSIONS In our pilot study, there was no reduction of the rate of levator ani avulsion in women with restrictive episiotomy compared with routine episiotomy. There were no differences in pelvic floor ultrasound parameters between the two groups.
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Affiliation(s)
- Teerayut Temtanakitpaisan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
| | - Suvit Bunyavejchevin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pranom Buppasiri
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chompilas Chongsomchai
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Yin X, Zhang D, Wang W, Xu Y. The Risk Factors of Postpartum Urinary Retention for Women by Vaginal Birth: A Systematic Review and Meta-Analysis. Int Urogynecol J 2024:10.1007/s00192-024-05853-w. [PMID: 38970657 DOI: 10.1007/s00192-024-05853-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 06/03/2024] [Indexed: 07/08/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Postpartum urinary retention is one of the most common complications in women during the immediate postpartum period. The objective was to systematically assess risk factors for postpartum urinary retention after vaginal delivery. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we retrieved relevant studies from PubMed, Embase, Cochrane Library, Web of Science Core Collection, China National Knowledge Internet, Wangfang Database, and Chinese Biomedical Database for observational studies investigating the risk factors for postpartum urinary retention from inception to 11 November 2022. The Newcastle-Ottawa Scale and Joanna Briggs Institute's tool were used to assess the risk of bias. We conducted a meta-analysis using RevMan 5.3. RESULTS In total, 3,074 articles were screened and data from 27 studies were used in the meta-analysis. Sixteen risk factors were identified, namely, labor augmentation (OR = 1.72, 95% CI = 1.17-2.51), primiparity (OR = 2.36, 95% CI = 1.64-3.38), manual fundal pressure (OR = 2.84, 95% CI = 1.00-8.11), perineal hematoma (OR = 7.28, 95% CI = 1.62-32.72), vulvar edema (OR = 7.99, 95% CI = 5.50-11.63), the total duration of labor (MD = 90.10, 95% CI = 49.11-131.08), the duration of the first stage of labor (MD = 33.97, 95% CI = 10.28-57.65), the duration of the second stage of labor (MD = 14.92, 95% CI = 11.79-18.05), the duration of the second stage of labor > 60 min (OR = 3.18, 95% CI = 1.32-7.67), mediolateral episiotomy (OR = 3.65, 95% CI = 1.70-7.83), severe perineal tear (OR = 3.21, 95% CI = 1.84-5.61), epidural analgesia (OR = 3.23, 95% CI = 1.50-6.96), forceps delivery (OR = 4.95, 95% CI = 2.88-8.51), vacuum delivery (OR = 2.44, 95% CI = 1.30-4.58), neonatal birth weight > 4,000 g (OR = 3.61, 95% CI = 1.96-6.65), and neonatal birth weight > 3,500 g (OR = 1.89, 95% CI = 1.12-3.19). CONCLUSIONS Our results demonstrated that labor augmentation, primiparity, manual fundal pressure, perineal hematoma, vulvar edema, the total duration of labor, the duration of the first stage of labor, the duration of the second stage of labor, the duration of the second stage of labor > 60 min, mediolateral episiotomy, severe perineal tear, epidural analgesia, forceps delivery, vacuum delivery, and neonatal birth weight > 4,000 g and > 3,500 g were risk factors for postpartum urinary retention in women with vaginal delivery. The specific ranges of the first and the second stages of labor causing postpartum urinary retention need to be clarified.
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Affiliation(s)
- Xiaohui Yin
- Department of Obstetrics & Gynecology, the Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Dakun Zhang
- Department of Urology, Beijing Longfu Hospital, Beijing, China
| | - Wei Wang
- Department of Obstetrics & Gynecology, the Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Yahong Xu
- School of Nursing, Fengtai District, Capital Medical University, No. 10, Xitoutiao, Youan Men, Beijing, China.
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Siafarikas F, Stær-Jensen J, Reimers C, Bø K, Ellström Engh M. Levator ani muscle avulsion and subsequent vaginal delivery: 8-year longitudinal follow-up. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 64:112-119. [PMID: 38285441 DOI: 10.1002/uog.27599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 01/16/2024] [Accepted: 01/19/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES To assess the evolution of levator ani muscle (LAM) avulsion from 1 year to 8 years after first delivery in women with and those without subsequent vaginal delivery. In addition, to assess whether women with full or partial avulsion 8 years after first delivery have larger LAM hiatal area and more symptoms of pelvic organ prolapse compared to women with normal LAM insertion. METHODS In this single-center longitudinal study, 195 women who were primiparous at the start of the study were included and underwent transperineal ultrasound examination 1 year and 8 years after first delivery. Muscle insertion was assessed by tomographic ultrasound imaging in the axial plane. Full LAM avulsion was defined as abnormal muscle insertion in all three central slices. Partial LAM avulsion was defined as abnormal muscle insertion in one or two central slices. Eight years after the first delivery, LAM hiatal area was assessed at rest, during maximum pelvic floor muscle contraction and on maximum Valsalva maneuver. To assess symptoms of pelvic organ prolapse, the vaginal symptoms module of the International Consultation on Incontinence Questionnaire was used. RESULTS At 1-year follow-up, 25 (12.8%) women showed signs of LAM avulsion, of whom 20 fulfilled the sonographic criteria of full avulsion and five of partial avulsion. Eight years after the first delivery, 35 (17.9%) women were diagnosed with avulsion, of whom 25 were diagnosed with full avulsion and 10 with partial avulsion. No woman with partial or full avulsion at 1 year had improved avulsion status at 8-year follow-up. Of the 150 women who had subsequent vaginal delivery, 21 (14.0%) women were diagnosed with partial or full LAM avulsion 1 year after first delivery, and 31 (20.7%) women were diagnosed with partial or full avulsion 8 years after first delivery. Of the 45 women without subsequent vaginal delivery, one woman with partial avulsion 1 year after first delivery was diagnosed with full avulsion at 8-year follow-up. All women with full avulsion at 1-year follow-up were diagnosed with full avulsion at 8-year follow-up regardless of whether they had subsequent vaginal delivery. At 8-year follow-up, women with full avulsion had statistically significantly larger LAM hiatal area compared to women with normal muscle insertion. Mean ± SD vaginal symptom scores ranged between 5.5 ± 5.7 and 6.0 ± 4.0 and vaginal symptom quality of life scores ranged between 0.9 ± 1.4 and 1.5 ± 2.2 and did not differ significantly between women with normal muscle insertion and women with partial or full avulsion at 8-year follow-up. CONCLUSIONS More LAM avulsions were present 8 years compared with 1 year after first delivery in women with subsequent vaginal delivery. Except for one primipara, all women without subsequent vaginal delivery had unchanged LAM avulsion status between 1 year and 8 years after their first delivery. Larger LAM hiatal area was found in women with full avulsion compared to those with normal muscle insertion at 8-year follow-up. Vaginal symptoms scores were low and did not differ between women with normal muscle insertion and those with partial or full avulsion at 8-year follow-up. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F Siafarikas
- University of Oslo, Faculty of Medicine, Division Akershus University Hospital, Oslo, Norway
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
| | - J Stær-Jensen
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
| | - C Reimers
- Department of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
| | - K Bø
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - M Ellström Engh
- University of Oslo, Faculty of Medicine, Division Akershus University Hospital, Oslo, Norway
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
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Gachon B, Fritel X, Pierre F, Nordez A. In vivo measurement of the elastic properties of pelvic floor muscles in pregnancy using shear wave elastography. Arch Gynecol Obstet 2024; 309:2623-2631. [PMID: 37535132 DOI: 10.1007/s00404-023-07174-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/23/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVE We aimed to investigate changes in the elastic properties of levator ani muscle (LAM) and external anal sphincter (EAS) during pregnancy using shear wave elastography (SWE). Our secondary objective was to examine the association between the elastic properties of pelvic floor muscles (PFM) and perineal tears at childbirth. METHODS This was a prospective monocentric study, including nulliparous women. Three visits were planned (14-18, 24-28, and 34-38 weeks) with a SWE assessment of the LAM and EAS at rest and during Valsalva maneuver. Then, we collected data about the delivery's characteristics. Assessments were performed using an Aixplorer V12® device (SL 18-5 linear probe) using a transperineal approach, reporting the shear modulus in kPa. We looked for changes in PFM's elastic properties during pregnancy using one-way ANOVA for repeated measures. We compared the mean shear modulus in late pregnancy for each muscle and condition between women with an intact perineum at delivery and those with a perineal tear using Student's t test. RESULTS Forty-seven women were considered. Forty-five women had vaginal delivery of which 38 (84.4%) had perineal tears. We did not report any significant changes in the elastic properties of PFM during pregnancy. Women with an intact perineum at delivery had a stiffer EAS at Valsalva maneuver in late pregnancy (27.0 kPa vs. 18.2 kPa; p < 0.005). CONCLUSIONS There were no significant changes in the elastic properties of the PFM in pregnancy. Stiffer EAS in late pregnancy appears to be associated with a lower incidence of perineal tears.
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Affiliation(s)
- Bertrand Gachon
- Department of Obstetrics and Gynecology, Poitiers University Hospital, Poitiers University, Poitiers, France.
- Nantes Université, Movement-Interactions-Performance, MIP, UR4334, 44000, Nantes, France.
- Poitiers University, INSERM CIC 1402, Poitiers University Hospital, Poitiers, France.
- Clinique Bouchard, 77 Rue du Dr Escat, 13006, Marseille, France.
| | - Xavier Fritel
- Department of Obstetrics and Gynecology, Poitiers University Hospital, Poitiers University, Poitiers, France
- Poitiers University, INSERM CIC 1402, Poitiers University Hospital, Poitiers, France
| | - Fabrice Pierre
- Department of Obstetrics and Gynecology, Poitiers University Hospital, Poitiers University, Poitiers, France
| | - Antoine Nordez
- Nantes Université, Movement-Interactions-Performance, MIP, UR4334, 44000, Nantes, France
- Institut Universitaire de France (IUF), Paris, France
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DeLancey JO, Mastrovito S, Masteling M, Horner W, Ashton-Miller JA, Chen L. A unified pelvic floor conceptual model for studying morphological changes with prolapse, age, and parity. Am J Obstet Gynecol 2024; 230:476-484.e2. [PMID: 38036167 PMCID: PMC11210379 DOI: 10.1016/j.ajog.2023.11.1247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/02/2023]
Abstract
Several 2-dimensional and 3-dimensional measurements have been used to assess changes in pelvic floor structures and shape. These include assessment of urogenital and levator hiatus dimensions, levator injury grade, levator bowl volume, and levator plate shape. We argue that each assessment reflects underlying changes in an individual aspect of the overall changes in muscle and fascial structures. Vaginal delivery, aging, and interindividual variations in anatomy combine to affect pelvic floor structures and their connections in different ways. To date, there is no unifying conceptual model that permits the evaluation of how these many measures relate to one another or that reflects overall pelvic floor structure and function. Therefore, this study aimed to describe a unified pelvic floor conceptual model to better understand how the aforementioned changes to the pelvic floor structures and their biomechanical interactions affect pelvic organ support with vaginal birth, prolapse, and age. In this model, the pelvic floor is composed of 5 key anatomic structures: the (1) pubovisceral, (2) puborectal, and (3) iliococcygeal muscles with their superficial and inferior fascia; (4) the perineal membrane or body; and (5) the anal sphincter complex. Schematically, these structures are considered to originate from pelvic sidewall structures and meet medially at important connection points that include the anal sphincter complex, perineal body, and anococcygeal raphe. The pubovisceral muscle contributes primarily to urogenital hiatus closure, whereas the puborectal muscle is mainly related to levator hiatus closure, although each muscle contributes to the other. Dorsally and laterally, the iliococcygeal muscle forms a shelflike structure in women with normal support that spans the remaining area between these medial muscles and attachments to the pelvic sidewall. Other features include the levator plate, bowl volume, and anorectal angle. The pelvic floor conceptual model integrates existing observations and points out evident knowledge gaps in how parturition, injury, disease, and aging can contribute to changes associated with pelvic floor function caused by the detachment of one or more important connection points or pubovisceral muscle failure.
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Affiliation(s)
- John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Sara Mastrovito
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Obstetrics and Gynecology, Istituto di Ricovero e Cura a Carattere Scientifico, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy.
| | - Mariana Masteling
- Departments of Mechanical Engineering, University of Michigan, Ann Arbor, MI
| | - Whitney Horner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - James A Ashton-Miller
- Departments of Mechanical Engineering, University of Michigan, Ann Arbor, MI; Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
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Woon Wong K, Okeahialam N, Thakar R, Sultan AH. Obstetric risk factors for levator ani muscle avulsion: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2024; 296:99-106. [PMID: 38422805 DOI: 10.1016/j.ejogrb.2024.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/15/2023] [Accepted: 02/22/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES Women have a 11% lifetime risk of undergoing surgery for vaginal prolapse. Levator ani muscle (LAM) avulsion is one etiological factor associated with primary and recurrent pelvic organ prolapse. Pelvic organ prolapse has been shown to greatly affect the quality of life and well-being of women. Conduct a meta-analysis identifying risk factors associated with LAM avulsion recognised on transperineal ultrasound (TPUS) or magnetic resonance imaging (MRI) in primiparous women after vaginal birth. STUDY DESIGN OVID Medline, Embase and the Cochrane Library from inception to January 2021 were searched. Review Manager 5.3 (The Cochrane Collaboration) was used to analyse data. Odds ratios (OR) with 95% confidence intervals (95% CIs) were calculated. The heterogeneity among studies was calculated using the I2statistic. RESULTS Twenty-five studies were eligible for inclusion (n = 9333 women). Major LAM avulsion was diagnosed in an average of 22 % (range 12.7-39.5 %) of cases. Twenty-two studies used TPUS and three used MRI to diagnose avulsion. Modifiable and non-modifiable risk factors were identified. Significant predictors identified were forceps (OR 6.25 [4.33 - 9.0]), obstetric anal sphincter injuries (OR 3.93 [2.85-5.42]), vacuum (OR 2.41 [1.40-4.16]), and maternal age (OR 1.06 [1.02-1.10]). CONCLUSIONS This is the first meta-analysis of both modifiable and non-modifiable risk factors associated with LAM avulsion. This information could be used to develop a clinically applicable risk prediction model to target postnatal women at risk of LAM avulsion with a view to prevent the onset of pelvic floor organ prolapse.
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Affiliation(s)
| | | | - Ranee Thakar
- Croydon University Hospital, UK; St George's University of London, UK
| | - Abdul H Sultan
- Croydon University Hospital, UK; St George's University of London, UK.
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Sorel M, Gachon B, Coste-Mazeau P, Aubard Y, Pierre F, Fradet L. Analysis of the obstetrician's posture and movements during a simulated forceps delivery. BMC Pregnancy Childbirth 2024; 24:253. [PMID: 38589802 PMCID: PMC11000395 DOI: 10.1186/s12884-024-06457-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 03/27/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND The objective of this study was to identify and qualify, by means of a three-dimensional kinematic analysis, the postures and movements of obstetricians during a simulated forceps birth, and then to study the association of the obstetricians' experience with the technique adopted. METHOD Fifty-seven volunteer obstetricians, 20 from the Limoges and 37 from the Poitiers University hospitals, were included in this multi-centric study. They were classified into 3 groups: beginners, intermediates, and experts, beginners having performed fewer than 10 forceps deliveries in real conditions, intermediates between 10 and 100, and experts more than 100. The posture and movements of the obstetricians were recorded between December 2020 and March 2021 using an optoelectronic motion capture system during simulated forceps births. Joint angles qualifying these postures and movements were analysed between the three phases of the foetal traction. These phases were defined by the passage of a virtual point associated with the forceps blade through two anatomical planes: the mid-pelvis and the pelvic outlet. Then, a consolidated ascending hierarchical classification (AHC) was applied to these data in order to objectify the existence of groups of similar behaviours. RESULTS The AHC distinguished four different postures adopted when crossing the first plane and three different traction techniques. 48% of the beginners adopted one of the two raised posture, 22% being raised without trunk flexion and 26% raised with trunk flexion. Conversely, 58% of the experts positioned themselves in a "chevalier servant" posture (going down on one knee) and 25% in a "squatting" posture before initiating traction. The results also show that the joint movement amplitude tends to reduce with the level of expertise. CONCLUSION Forceps delivery was performed in different ways, with the experienced obstetricians favouring postures that enabled observation at the level of the maternal perineum and techniques reducing movement amplitude. The first perspective of this work is to relate these different techniques to the traction force generated. The results of these studies have the potential to contribute to the training of obstetricians in forceps delivery, and to improve the safety of women and newborns.
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Affiliation(s)
- Manon Sorel
- Department of Obstetrics and Gynecology, University of Poitiers, University Hospital Center of Poitiers, Poitiers, 86000, France.
- Pprime Institute UPR 3346-CNRS, University of Poitiers, Axe RoBioSS, Poitiers, 86073, France.
| | - Bertrand Gachon
- Department of Obstetrics and Gynecology, University of Poitiers, University Hospital Center of Poitiers, Poitiers, 86000, France
- Clinical Investigation Center, INSERM CIC 1402, Poitiers, 86000, France
| | - Perrine Coste-Mazeau
- Department of Obstetrics and Gynecology, University of Limoges, University Hospital Center of Limoges, Limoges, 87000, France
| | - Yves Aubard
- Department of Obstetrics and Gynecology, University of Limoges, University Hospital Center of Limoges, Limoges, 87000, France
| | - Fabrice Pierre
- Department of Obstetrics and Gynecology, University of Poitiers, University Hospital Center of Poitiers, Poitiers, 86000, France
| | - Laetitia Fradet
- Pprime Institute UPR 3346-CNRS, University of Poitiers, Axe RoBioSS, Poitiers, 86073, France
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DeLancey JO, Pipitone F, Masteling M, Xie B, Ashton-Miller JA, Chen L. Functional Anatomy of Urogenital Hiatus Closure: the Perineal Complex Triad Hypothesis. Int Urogynecol J 2024; 35:441-449. [PMID: 38206338 PMCID: PMC11060667 DOI: 10.1007/s00192-023-05708-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/18/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Urogenital hiatus enlargement is a critical factor associated with prolapse and operative failure. This study of the perineal complex was performed to understand how interactions among its three structures: the levator ani, perineal membrane, and perineal body-united by the vaginal fascia-work to maintain urogenital hiatus closure. METHODS Magnetic resonance images from 30 healthy nulliparous women with 3D reconstruction of selected subjects were used to establish overall geometry. Connection points and lines of action were based on perineal dissection in 10 female cadavers (aged 22-86 years), cross sections of 4 female cadavers (aged 14-35 years), and histological sections (cadavers aged 16 and 21 years). RESULTS The perineal membrane originates laterally from the ventral two thirds of the ischiopubic rami and attaches medially to the perineal body and vaginal wall. The levator ani attaches to the perineal membrane's cranial surface, vaginal fascia, and the perineal body. The levator line of action in 3D reconstruction is oriented so that the levator pulls the medial perineal membrane cranio-ventrally. In cadavers, simulated levator contraction and relaxation along this vector changes the length of the membrane and the antero-posterior diameter of the urogenital hiatus. Loss of the connection of the left and right perineal membranes through the perineal body results in diastasis of the levator and a widened hiatus, as well as a downward rotation of the perineal membrane. CONCLUSION Interconnections involving the levator ani muscles, perineal membrane, perineal body, and vaginal fascia form the perineal complex surrounding the urogenital hiatus in an arrangement that maintains hiatal closure.
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Affiliation(s)
- John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Fernanda Pipitone
- Department of Obstetrics and Gynecology, University of São Paulo, São Paulo, Brazil
| | - Mariana Masteling
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Bing Xie
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | | | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, 48109, USA
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Sorel M, Fradet L, Coste-Mazeau P, Aubard Y, Pizzoferrato AC, Pierre F, Gachon B. A new approach to assessing the obstetrician's posture and movement during an instrumental forceps delivery. J Gynecol Obstet Hum Reprod 2023; 52:102654. [PMID: 37643694 DOI: 10.1016/j.jogoh.2023.102654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION The number of deliveries by forceps decreases significantly in favour of the vacuum. Now, when the use of forceps is necessary, physicians less experimented with this procedure are likely to induce serious and preventable perineal or foetal injuries. Training therefore becomes essential. However, there are no clear recommendations on the technique to perform a delivery by forceps, namely the body posture and gesture to adopt. Our goal is then to provide a protocol that can help to determine if there is an optimal technique to perform a delivery by forceps. METHOD We will include voluntary participants whose level of experience and type of practice differ. We will propose to record their postures and gestures using an optoelectronic motion analysis system during a forceps delivery simulated on a mannequin. We will also measure the traction force produced by the subject on the forceps using force platforms and technical markers placed on the forceps. We will then perform a principal component analysis to look for similar motion patterns. EXPECTED RESULTS We plan to analyse about fifty participants (25 seniors and 25 juniors). Our hypothesis is that the realism of the simulation will be deemed satisfactory by the participants, that the experimental conditions will not modify their gestures, and that the degree of experience will result in different techniques. CONCLUSION A better knowledge on the posture and gesture to adopt to realise a forceps delivery should improve the safety of women and new-borns. The results of this study could also be a valuable contribution for the training of obstetricians.
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Affiliation(s)
- Manon Sorel
- Department of Obstetrics and Gynecology, University Hospital Center of Poitiers, 2 rue de la Milétrie, CS 90577, 86021 Poitiers Cedex, France.
| | - Laetitia Fradet
- Pprime Institute UPR 3346-CNRS, Axe RoBioSS, University of Poitiers, 2 Boulevard des Frères Lumière 86360 Chasseneuil-du-Poitou, France
| | - Perrine Coste-Mazeau
- Department of Obstetrics and Gynecology, University Hospital Center of Limoges, 2 Avenue Martin Luther King 87000 Limoges, France
| | - Yves Aubard
- Department of Obstetrics and Gynecology, University Hospital Center of Limoges, 2 Avenue Martin Luther King 87000 Limoges, France
| | - Anne-Cécile Pizzoferrato
- Department of Obstetrics and Gynecology, University Hospital Center of Poitiers, 2 rue de la Milétrie, CS 90577, 86021 Poitiers Cedex, France; Clinical investigation center, INSERM CIC 1402, Entrée 5 - Cours Est Jean Bernard CHU de Poitiers 2 rue de la Milétrie 86000 Poitiers, France
| | - Fabrice Pierre
- Department of Obstetrics and Gynecology, University Hospital Center of Poitiers, 2 rue de la Milétrie, CS 90577, 86021 Poitiers Cedex, France
| | - Bertrand Gachon
- Department of Obstetrics and Gynecology, University Hospital Center of Poitiers, 2 rue de la Milétrie, CS 90577, 86021 Poitiers Cedex, France; Clinical investigation center, INSERM CIC 1402, Entrée 5 - Cours Est Jean Bernard CHU de Poitiers 2 rue de la Milétrie 86000 Poitiers, France; Motricité Interaction Performance, EA 4334, University of Nantes, 23 rue du Recteur Schmitt Bâtiment F0 - BP 92235 44322 Nantes France
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10
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Duarte Thibault M, Chen L, Huebner M, DeLancey JO, Swenson CW. A comparison of MRI-based pelvic floor support measures between young and old women with prolapse. Int Urogynecol J 2023; 34:2081-2088. [PMID: 36971829 PMCID: PMC10566251 DOI: 10.1007/s00192-023-05505-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/14/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION AND HYPOTHESIS We sought to 1) test the hypothesis that young women (≤45 years) with pelvic organ prolapse have a higher prevalence of major levator ani muscle (LAM) defects than old women (≥70 years) with prolapse and 2) compare level II/III measurements between young and old women with prolapse and age-matched controls to evaluate age-related mechanistic differences in the disease process. METHODS A secondary analysis examined four groups of parous women: young prolapse (YPOP, n = 17); old prolapse (OPOP, n = 17); young controls (YC, n = 15); old controls, (OC, n = 13). Prolapse was defined as any compartment at or beyond the hymen with vaginal bulge symptoms. Genital hiatus (GH) was measured on clinical exam. Major LAM defects and level II/III measurements (UGH: urogenital hiatus, LA: levator area, and apex location) were assessed on MRI at rest and strain, and the difference (Δ) between measurements calculated. Principal component analysis was used to evaluate levator plate (LP) shape. RESULTS Major LAM defects occurred in 42% of YPOP and 47% of OPOP (p > .99). GHrest was 1.5 cm larger in OPOP versus YPOP (p < .001) and 2 cm larger in OPOP versus OC (p < .001). Regardless of prolapse status, LArest and UGHrest on MRI increased with age. YPOP had larger ΔLA (p = .04), ΔUGH (p = .03), and Δapex than OPOP (p = .01). Resting LP shape was more dorsally oriented in OPOP versus YPOP (p = .02) and OC versus YC (p = .004). CONCLUSIONS Prolapse in young women cannot be solely explained by a higher LAM defect prevalence. GH size and other measures of level II/III pelvic support worsen with age regardless of prolapse status.
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Affiliation(s)
- Mary Duarte Thibault
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
- Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Houston, TX, 77030, USA.
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Markus Huebner
- Department of Obstetrics and Gynecology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Tuebingen, Tuebingen, Germany
| | - John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Carolyn W Swenson
- Division of Urogynecology, Department of Obstetrics & Gynecology, University of Utah, Salt Lake City, UT, USA
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11
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Cheng W, English E, Horner W, Swenson CW, Chen L, Pipitone F, Ashton-Miller JA, DeLancey JOL. Hiatal failure: effects of pregnancy, delivery, and pelvic floor disorders on level III factors. Int Urogynecol J 2023; 34:327-343. [PMID: 36129480 PMCID: PMC10171831 DOI: 10.1007/s00192-022-05354-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/28/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The failure of the levator hiatus (LH) and urogenital hiatus (UGH) to remain closed is not only associated with pelvic floor disorders, but also contributes to recurrence after surgical repair. Pregnancy and vaginal birth are key events affecting this closure. An understanding of normal and failed hiatal closure is necessary to understand, manage, and prevent pelvic floor disorders. METHODS This narrative review was conducted by applying the keywords "levator hiatus" OR "genital hiatus" OR "urogenital hiatus" in PubMed. Articles that reported hiatal size related to pelvic floor disorders and pregnancy were chosen. Weighted averages for hiatal size were calculated for each clinical situation. RESULTS Women with prolapse have a 22% and 30% larger LH area measured by ultrasound at rest and during Valsalva than parous women with normal support. Women with persistently enlarged UGH have 2-3 times higher postoperative failure rates after surgery for prolapse. During pregnancy, the LH area at Valsalva increases by 29% from the first to the third trimester in preparation for childbirth. The enlarged postpartum hiatus recovers over time, but does not return to nulliparous size after vaginal birth. Levator muscle injury during vaginal birth, especially forceps-assisted, is associated with increases in hiatal size; however, it only explains a portion of hiatus variation-the rest can be explained by pelvic muscle function and possibly injury to other level III structures. CONCLUSIONS Failed hiatal closure is strongly related to pelvic floor disorders. Vaginal birth and levator injury are primary factors affecting this important mechanism.
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Affiliation(s)
- Wenjin Cheng
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
- Beaumont Hospital Dearborn, Department of Obstetrics and Gynecology, 18101 Oakwood Blvd, Dearborn, MI, 48124, USA.
| | - Emily English
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Michigan Medicine, University of Michigan Health-West, Grand Rapids, MI, USA
| | - Whitney Horner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Division of Urogynecology and Pelvic Reconstructive, University of Utah, Salt Lake City, UT, USA
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Fernanda Pipitone
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - James A Ashton-Miller
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - John O L DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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12
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García-Mejido JA, González-Diaz E, Ortega I, Martín-Martinez A, Fernández-Palacín A, Sainz-Bueno JA. Multicenter study of the evolution of different types of avulsion over the 12 months after delivery. Int J Gynaecol Obstet 2023; 160:93-97. [PMID: 35373338 PMCID: PMC10083999 DOI: 10.1002/ijgo.14208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To perform a multicenter study of muscle recovery in levator ani muscle (LAM) avulsion during the first 12 months postpartum according to the type of LAM avulsion suffered. METHODS This was a multicenter prospective observational study including 242 primiparas. Transperineal ultrasound was performed at 6 months and 12 months after delivery. Type I LAM avulsion was present when most of the lateral fibers of the pubovisceral muscle were observed at the muscle's insertion at the pubic level. Type II LAM avulsion was defined as complete detachment of the pubovisceral muscle from its insertion at the pubic level. RESULTS Among the 56 patients who completed the study (with ultrasound at 6 and 12 months after delivery), 76 avulsions (10 cases of bilateral avulsion) were identified at 6 months after delivery, and the total number of avulsions had decreased to 58 at 12 months after delivery (P < 0.001; 95% confidence interval [CI] 13.9%-33.5%). This decrease was due to the disappearance of 69.2% of the cases of Type I LAM avulsions (P < 0.001; 95% CI: 50.2%-88.2%). However, the number of Type II LAM avulsions remained constant at 6 months and 12 months after delivery. CONCLUSION The spontaneous resolution of LAM avulsion during the first 12 months postpartum occurs in cases of Type I LAM avulsion but is not observed in Type II LAM avulsion.
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Affiliation(s)
- José Antonio García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
| | - Enrique González-Diaz
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), León, Spain
| | - Ismael Ortega
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - Alicia Martín-Martinez
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - Ana Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - José Antonio Sainz-Bueno
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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13
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Episiotomy in vacuum extraction, do we cut the levator ani muscle? A prospective cohort study. Int Urogynecol J 2022; 33:3391-3399. [PMID: 35467140 DOI: 10.1007/s00192-022-05188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Vaginal delivery may lead to levator ani muscle (LAM) injury or avulsion. Episiotomy may reduce obstetric anal sphincter injury in operative vaginal delivery, but may increase the risk of LAM injury. Our aim was to assess whether lateral episiotomy in vacuum extraction (VE) in primiparous women causes LAM injury. METHODS A prospective cohort study of 58 primiparous women with episiotomy nested within an ongoing multicenter randomized controlled trial of lateral episiotomy versus no episiotomy in VE (EVA trial) was carried out in Sweden. LAM injury was evaluated using 3D endovaginal ultrasound 6-12 months after delivery and Levator Ani Deficiency (LAD) score. Episiotomy scar properties were measured. Characteristics were described and compared using Chi-squared tests. We stipulated that if a lateral episiotomy cuts the LAM, ≥50% would have a LAM injury. Among those, ≥50% would be side specific. We compared the observed prevalence with a test of one proportion. RESULTS Twelve (20.7%, 95% CI 10.9-32.9) of 58 women had a LAD (p < 0.001, compared with the stipulated 50%). Six (50.0%, 95% CI 21.1% to 78.9%) of 12 women had a LAD on the episiotomy side, including those with bilateral LAD (p = 1.00). Two (16.7%, 95% CI 2.1% to 48.4%) of 12 women had a LAD exclusively on the episiotomy side (p = 0.02). CONCLUSIONS There was no excessive risk of cutting the LAM while performing a lateral episiotomy. LAD was not seen in women with episiotomies shorter than 18 mm.
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14
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Pipitone F, DeLancey JO. The postpartum silence. BJOG 2022; 129:1231-1233. [PMID: 35226407 DOI: 10.1111/1471-0528.17130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/09/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Fernanda Pipitone
- Hospital das Clínicas FMUSP, University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil.,Pelvic Floor Research Group, University of Michigan, Ann Arbor, Michigan, USA
| | - John O DeLancey
- Pelvic Floor Research Group, University of Michigan, Ann Arbor, Michigan, USA.,Department of Obstetrics and Gynecology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
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15
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García-Mejido JA. Re: The evolution of levator ani muscle trauma over the first 9 months after vaginal birth. Neurourol Urodyn 2022; 41:1046-1047. [PMID: 35293627 DOI: 10.1002/nau.24910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 02/27/2022] [Indexed: 11/10/2022]
Affiliation(s)
- José Antonio García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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