Pelvic floor trauma in childbirth - myth or reality?

Effect of structured pelvic floor muscle training on pelvic floor muscle contraction and treatment of pelvic organ prolapse in postpartum women: ultrasound and clinical evaluations

OBJECTIVES

The purpose of this study is to examine the impact of structured pelvic floor muscle training (PFMT) on pelvic floor muscle (PFM) contraction and the treatment of pelvic organ prolapse (POP) in postpartum women.

METHODS

Sixty patients who volunteered for a PFMT assessment at 6-8 weeks after delivery were included in this retrospective analysis. For 5 weeks, all patients had structured PFMT, which included supervised daily pelvic muscle contractions, biofeedback therapy, and electrical stimulation. The main outcomes were POP stage assessed by POP quantification (POP-Q), pelvic organ position and hiatus area (HA) assessed by transperineal ultrasound, PFM contraction assessed by Modified Oxford scale (MOS), surface electromyography (EMG), and sensation of PFM graded using visual analog scale (VAS).

RESULTS

Structured PFMT was associated with better POP-Q scores in Aa, Ba, C, and D (p values were 0.01, 0.001, 0.017, and 0.001 separately). The bladder neck at rest and maximum Valsalva, the cervix position and HA at maximum Valsalva in transperineal ultrasound were significantly better than before (p values were 0.031, < 0.001, 0.043, and < 0.001 separately). PFM contraction assessed by MOS, EMG, and PFM VAS score were significantly improved (all p values were < 0.001). However, no significant improvement was observed in POP-Q stage.

CONCLUSIONS

Structured PFMT can increase PFM function in postpartum women but cannot modify the POP-Q stage. Transperineal ultrasonography is a useful method for evaluating therapy efficacy objectively. More randomized controlled trials are needed before definitive conclusions can be drawn about the effect of structured PFMT on POP in postpartum women.

Associations of Maternal Complaints to Levator Ani Muscle Trauma within 9 Months after Vaginal Birth: A Prospective Observational Cohort Study

Introduction. Pelvic floor trauma in the form of partial or complete avulsions of the levator ani muscle (LAM) affects 6-42% of women after vaginal birth and can cause tremendous long-term morbidity. Many studies assessed morphological pelvic floor trauma after childbirth but lacked to evaluate women’s associated short-term complaints. A proper assessment of trauma and subjective complaints after birth could help to assess possible associations between them and their relevance to women’s daily life. Therefore, we aimed to assess women’s complaints within the first months after birth in association to their LAM trauma. Materials and Methods. Between 3/2017 and 4/2019, we prospectively evaluated vaginal births of 212 primiparous women with singletons in $\text{vertex}\text{presentation}\ge 36+0$ gestational weeks for levator ani muscle (LAM) trauma by translabial ultrasound, for pelvic organ prolapse by clinical examination, and for urogynecological complaints using questionnaires 1-4 days (P1), 6-10 weeks (P2), and 6-9 months (P3) after birth. The questionnaires were self-designed but oriented to and modified from validated questionnaires. Women’s complaints were evaluated for P1-P3 according to their LAM trauma state. Results. At P1, 67% of women showed an intact LAM, whereas 14.6% presented a hematoma, 6.6% a partial avulsion (PAV), and 11.8% a complete avulsion (CAV). At P2, 75.9% showed an intact LAM, 9.9% a PAV, and 14.2% a CAV. At P3, 72.9% of women with a LAM trauma in P1 and/or P2 were assessed with 21.6% being intact and 39.2% having a PAV and CAV, respectively. Obstetrical and baseline characteristics differed slightly between the groups. When comparing the time before and during pregnancy with the time after childbirth, birth itself affected women’s complaints in all LAM state groups, but the presence of a LAM trauma, especially a CAV, had more negative effects. Conclusions. Vaginal birth changes the anatomical structure of the maternal birth canal and genital tract, and it alters women’s perceptions and body function. In our study, LAM trauma did not change these effects tremendously within the first months. Therefore, other maternal, fetal, and obstetrical factors need consideration for the explanation of maternal complaints, in addition to long-term effects of trauma and dysfunction of the LAM and other birth canal structures.

2D pelvic floor ultrasound imaging in identifying levator ani muscle trauma agrees highly with 4D ultrasound imaging

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the agreement between 2D and 4D translabial ultrasound (TLUS) technique in showing levator ani muscle (LAM) states after vaginal birth.

METHODS

In a prospective observational cohort study between March 2017 and April 2019 we evaluated LAM states (intact, hematoma, partial, complete avulsion) of primiparous women having given birth vaginally with singletons in vertex presentation ≥ 36+0 gestational weeks by using 2D and 4D TLUS within 1-4 days postpartum (assessment A1) and again 6-10 weeks postpartum (assessment A2). Cohen's Kappa analysis was performed for each side separately to evaluate the test agreement between the two ultrasound techniques at every assessment period.

RESULTS

A total of 224 women participated at A1 and 213 at A2. The agreement between the two ultrasound techniques was good to very good at A1 (Cohen`s kappa right-sided 0.78, left-sided 0.82) and very good at A2 (Cohen`s kappa both sides 0.88). The agreement was best when assessing an intact LAM or a complete avulsion (Cohen`s kappa between 0.78-0.92 for complete avulsions).

CONCLUSIONS

The comparison between 2D and 4D TLUS showed a good to very good agreement in LAM trauma immediately after birth as well as 6-10 weeks postpartum. Therefore, 2D ultrasound could also be a valuable method for demonstrating a LAM abnormality and could be used in settings where 3D/4D ultrasound equipment is not available.

The evolution of levator ani muscle trauma over the first 9 months after vaginal birth

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the evolution of levator ani muscle (LAM) trauma over the first 9 months after birth and to evaluate their agreement between different assessment periods.

METHODS

From March 2017 to April 2019 we prospectively evaluated LAM states (intact, hematoma, partial or complete avulsion) of primiparous women after vaginal birth by using 4D translabial ultrasound (TLUS) at three different assessment periods. All women were examined 1-4 days (A1) and 6-10 weeks (A2) postpartum, and women with a trauma additionally 6-9 months postpartum (A3). Cohen's Kappa analysis was performed to evaluate the test agreement between the assessment periods.

RESULTS

Thirty-two percent of the women at A1 had a LAM trauma and 24% at A2. The higher number of LAM injuries at A1 can be explained by hematomas (14%), of which 51% spontaneously resolved at A2, 35% revealed themselves as partial, and 12% as complete avulsions. At A3, we observed anatomical improvement from complete to partial avulsions (23%) and few partial avulsions changed into an intact LAM (3%); none of the complete avulsions changed into an intact LAM. The agreement of 4D TLUS between A1 and A2 was moderate to good (0.64 for the right-sided LAM/0.60 for the left-sided LAM) and between A2 and A3 good to very good (0.76 right-sided/0.84 left-sided).

CONCLUSIONS

Levator ani muscle trauma can reliably be diagnosed during all assessment periods. However, the agreement between A1 and A2 was only moderate to good. This can be explained by hematomas inside the LAM that were only observed early postpartum. We observed some anatomical improvement at A3, but no complete avulsion improved to an intact LAM.

Influence of a Virtual Exercise Program throughout Pregnancy during the COVID-19 Pandemic on Perineal Tears and Episiotomy Rates: A Randomized Clinical Trial

The complications associated with COVID-19 confinement (impossibility of grouping, reduced mobility, distance between people, etc.) influence the lifestyle of pregnant women with important associated complications regarding pregnancy outcomes. Therefore, perineal traumas are the most common obstetric complications during childbirth. The aim of the present study was to examine the influence of a supervised virtual exercise program throughout pregnancy on perineal injury and episiotomy rates during childbirth. A randomized clinical trial design (NCT04563065) was used. Data were collected from 98 pregnant women without obstetric contraindications who attended their prenatal medical consultations. Women were randomly assigned to the intervention (IG, N = 48) or the control group (CG, N = 50). A virtual and supervised exercise program was conducted from 8-10 to 38-39 weeks of pregnancy. Significant differences were found between the study groups in the percentage of episiotomies, showing a lower episiotomy rate in the IG (N = 9/12%) compared to the CG (N = 18/38%) (χ² (3) = 4.665; p = 0.031) and tears (IG, N = 25/52% vs. CG, N = 36/73%) (χ² (3) = 4.559; p = 0.033). A virtual program of supervised exercise throughout pregnancy during the current COVID-19 pandemic may help reduce rates of episiotomy and perineal tears during delivery in healthy pregnant women.

Association between the side of levator Ani muscle trauma and fetal position at birth - a prospective observational study

INTRODUCTION

Trauma of the levator ani muscle (LAM) is common after vaginal birth and can most reliably be diagnosed by 3-dimensional (3D) translabial ultrasound (TLUS). Multiple risk factors are known in general, but not in association to a specific side of the body. Therefore, our aim was to evaluate different impact factors which cause LAM trauma on either side of the body or bilateral by focusing on the fetal position at birth.

MATERIAL AND METHODS

As part of a prospective cohort study between 3/2017 and 4/2019, we analyzed vaginal births of nulliparous women with singletons in vertex presentation≥36+0 gestational weeks. We evaluated their pelvic floor for hematomas, partial and complete LAM avulsions by 3D TLUS 2-4 days postpartum and searched for an association between the affected body side and different fetal, maternal and obstetrical factors.

RESULTS

71 out of 213 women (33.3%) suffered from LAM trauma - 17 (23.9%) on the right side, 20 (28.2%) on the left side and 34 (47.9%) bilateral. No association between the different evaluated factors and the affected body side could be identified, except for the quality of fetal heart rate tracing.

CONCLUSIONS

No significant impact factors of LAM trauma could be associated with a specific side of the body. Other possible mechanisms need investigation in the future, such as the time of the birth canal and the fetus to adapt to each other, including adequate time for the tissue to stretch and the fetus to rotate into the ideal position within the LAM hiatus.

EINLEITUNG

Levatormuskelverletzungen sind häufig nach Vaginalgeburten und können zuverlässig mittels translabialem 3D-Ultraschall diagnostiziert werden. Diverse Risikofaktoren sind hierfür bekannt, allerdings keine hinsichtlich der Assoziation zu einer der beiden Körperseiten. Daher war das Ziel dieser Arbeit, verschiedene Einflussfaktoren im Rahmen vaginaler Geburten zu evaluieren, welche eine Levatorverletzung auf einer der beiden Körperseiten bzw. beidseitig begünstigen, v. a. hinsichtlich der Kindsposition im Geburtskanal.

MATERIAL UND METHODIK

In einer prospektiven Kohortenstudie analysierten wir von 3/2017-4/2019 Erstgebärende mit vaginalen Einlingsgeburten aus Schädellage≥36+0 SSW. Wir evaluierten 2-4 Tage postpartal ihren Beckenboden mittels 3D-Ultraschall hinsichtlich Hämatomen sowie partiellen und kompletten Levatoravulsionen und suchten nach Assoziationen zwischen der betroffenen Körperseite und fetalen, maternalen und geburtshilflichen Einflussfaktoren.

ERGEBNISSE

Von 213 Frauen erlitten 71 (33.3%) eine Levatorverletzung - 17 (23.9%) rechtsseitig, 20 (28.2%) linksseitig und 34 (47.9%) beidseitig. Es wurden keine Assoziationen zwischen den untersuchten Einflussfaktoren und der betroffenen Körperseite gefunden, bis auf die Qualität der fetalen Herzfrequenz.

DISKUSSION

Es konnten keine signifikanten Einflussfaktoren für das Auftreten einer Levatorverletzung einer spezifischen Körperseite eruiert werden. Daher bedarf es in Zukunft der Untersuchung weiterer Mechanismen, wie der Adaptationsvorgänge von Geburtskanal und Fet und der adäquaten Zeit für das Gewebe zur notwendigen Dehnung, v. a. im Bereich der Levatoröffnung.

Prediction of levator ani muscle avulsion by genital tears after vaginal birth-a prospective observational cohort study

INTRODUCTION

Visible birth tears and levator ani muscle (LAM) trauma are common after birth. For the diagnosis of LAM trauma ultrasound evaluation is advisable. As ultrasound equipment and trained personnel are not available everywhere at all times, we aimed to evaluate whether specific overt birth tears are an indicator for LAM trauma.

METHODS

In a prospective cohort study at our center from March 2017-April 2019, we evaluated vaginal births of nulliparous women with singletons in vertex presentation ≥ 36 + 0 gestational weeks for LAM trauma by translabial ultrasound and for overt birth tears by inspection. We then calculated the association of overt birth tears with complete LAM avulsion.

RESULTS

Of 213 women, 23.9% had any kind of LAM trauma, with 14.1% being complete avulsions. In univariate analysis, solely high-grade perineal tears (OASIS) were significantly associated with complete LAM avulsions.

CONCLUSIONS

Fourteen percent of women suffered a complete LAM avulsion after vaginal birth, with OASIS being the only associated parameter of significance. The occurrence of such trauma might be an indicator for a mismatch between the size of the fetus and the structures of the birth canal, leading to birth trauma. Assessing for LAM trauma by translabial ultrasound in women with OASIS might be worthwhile.

Atraumatic normal vaginal delivery: how many women get what they want?

BACKGROUND

Trauma to the perineum, levator ani complex, and anal sphincter is common during vaginal childbirth, but often clinically underdiagnosed, and many women are unaware of the potential for long-term damage.

OBJECTIVE

In this study we use transperineal ultrasound to identify how many women will achieve a normal vaginal delivery without substantial damage to the levator ani or anal sphincter muscles, and to create a model to predict patient characteristics associated with successful atraumatic normal vaginal delivery.

STUDY DESIGN

This is a retrospective, secondary analysis of data sets gathered in the context of an interventional perinatal imaging study. A total of 660 primiparas, carrying an uncomplicated singleton pregnancy, underwent an antepartum and postpartum interview, vaginal exam (Pelvic Organ Prolapse Quantification), and 4-dimensional translabial ultrasound. Ultrasound data were analyzed for levator trauma and/or overdistention and residual sphincter defects. Postprocessing analysis of ultrasound volumes was performed blinded against clinical data and analyzed against obstetric data retrieved from the local maternity database. Levator avulsion was diagnosed if the muscle insertion at the inferior pubic ramus at the plane of minimal hiatal dimensions and within 5 mm above this plane on tomographic ultrasound imaging was abnormal, ie the muscle was disconnected from the inferior pubic ramus. Hiatal overdistensibility (microtrauma) was diagnosed if there was a peripartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm². A sphincter defect was diagnosed if a gap of >30 degrees was seen in ≥4 of 6 tomographic ultrasound imaging slices bracketing the external anal sphincter. Two models were tested: a first model that defines severe pelvic floor trauma as either obstetric anal sphincter injury or levator avulsion, and a second, more conservative model, that also included microtrauma.

RESULTS

A total of 504/660 women (76%) returned for postpartum follow-up as described previously. In all, 21 patients were excluded due to inadequate data or intercurrent pregnancy, leaving 483 women for analysis. Model 1 defined nontraumatic vaginal delivery as excluding operative delivery, obstetric anal sphincter injuries, and sonographic evidence of levator avulsion or residual sphincter defect. Model 2 also excluded microtrauma. Of 483 women, 112 (23%) had a cesarean delivery, 103 (21%) had an operative vaginal delivery, and 17 (4%) had a third-/fourth-degree tear, leaving 251 women who could be said to have had a normal vaginal delivery. On ultrasound, in model 1, 27 women (6%) had an avulsion and 31 (6%) had a residual defect, leaving 193/483 (40%) who met the criteria for atraumatic normal vaginal delivery. In model 2, an additional 33 women (7%) had microtrauma, leaving only 160/483 (33%) women who met the criteria for atraumatic normal vaginal delivery. On multivariate analysis, younger age and earlier gestation at time of delivery remained highly significant as predictors of atraumatic normal vaginal delivery in both models, with increased hiatal area on Valsalva also significant in model 2 (all P ≤ .035).

CONCLUSION

The prevalence of significant pelvic floor trauma after vaginal child birth is much higher than generally assumed. Rates of obstetric anal sphincter injury are often underestimated and levator avulsion is not included as a consequence of vaginal birth in most obstetric text books. In this study less than half (33-40%) of primiparous women achieved an atraumatic normal vaginal delivery.

Prevalence and factors associated with urinary incontinence in climacteric

OBJECTIVE

To estimate the prevalence and identify associated factors to urinary incontinence (UI) in climacteric women.

METHOD

In a cross-sectional study with a stratified random sample, 1,200 women aged between 35 and 72 years were studied, enrolled in the Family Health Strategy in the city of Pindamonhangaba, São Paulo. Urinary incontinence was investigated using the International Consultation of Incontinence Questionnaire - Short Form, while associated factors were assessed based on a self-reported questionnaire with socio-demographic, obstetric and gynecological history, morbidities and drug use. The prevalence of urinary incontinence was estimated with a 95% confidence interval (95CI) and the associated factors were identified through multiple logistic regression model performed using Stata software, version 11.0.

RESULTS

Women had a mean age of 51.9 years, most were in menopause (59.4%), married (87.5%), Catholic (48.9%), and declared themselves black or brown (47.2%). The mean age of menopause of women with UI was 47.3 years. The prevalence of UI was 20.4% (95CI: 17.8-23.1%). The factors associated with UI were urinary loss during pregnancy (p=0.000) and after delivery (p=0.000), genital prolapse (p=0.000), stress (p=0.001), depression (p=0.002), and obesity (p=0.006).

CONCLUSION

The prevalence of UI was lower but similar to that found in most similar studies. Factors associated with the genesis of UI were urinary loss during pregnancy and after delivery, genital prolapse and obesity.

Postpartum vaginal cystic lesions: everyday practice or a differential diagnosis challenge?

Postpartum vaginal cystic lesions constitute a common situation that is caused either by inflammation or by accumulation of lymph. We report a case of a 33-year-old woman who had bilateral duplication of the pelvicalyceal system and ureter, and after the labor of her second child, she had one ureter prolapse into the vagina after initially appearing as a cystic lesion. Ureteral duplication is the most common renal abnormality, occurring in approximately 1% of the population and in 10% of children who are diagnosed with urinary tract infections. In our case we consider possible that this clinical situation was a result of a combination of postpartum pelvic floor trauma and prolapse of the ureter. There are only several of these cases in the literature where ureter prolapse is associated and complicated by pelvic floor trauma caused during or after labor. The clinical approach of the cystic lesions located in the vagina during the postpartum period should include a meticulous examination of the urinary system before any other medical practice.

Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) is the most common type of urinary incontinence (UI) in pregnant women and is known to have detrimental effects on the quality of life in approximately 54.3 %. Pregnancy is the main risk factor for the development of SUI. This review provides details of the pathophysiology leading to SUI in pregnant women and SUI prevalence and treatment during pregnancy.

METHODS

We conducted a PubMed search for English-language and human-study articles registered from January 1990 to September 2012. This search was performed for articles dealing with prevalence and treatment of SUI during pregnancy. In the intervention studies, we included studies that used a randomized controlled trial (RCT) design or studies comparing a treatment intervention to no treatment.

RESULTS

A total of 534 articles were identified; 174 full-text articles were reviewed, and 28 of them met eligibility criteria and are reported on here. The mean prevalence of SUI during pregnancy was 41 % (18.6-60 %) and increased with gestational age. The increasing pressure of the growing uterus and fetal weight on pelvic-floor muscles (PFM) throughout pregnancy, together with pregnancy-related hormonal changes, may lead to reduced PFM strength as well as their supportive and sphincteric function. These cause mobility of the bladder neck and urethra, leading to urethral sphincter incompetence. Pelvic floor muscle exercise (PFME) is a safe and effective treatment for SUI during pregnancy, without significant adverse effects.

CONCLUSIONS

Understanding these issues can be useful for health-care professionals when informing and counseling pregnant women to help prevent SUI during pregnancy and the postpartum period.

Rectocele--does the size matter?

OBJECTIVES

Large rectoceles (>2 cm) are believed to be associated with difficulty in evacuation, constipation, rectal pain, and rectal bleeding. The aim of our study was to determine whether rectocele size is related to patient's symptoms or defecatory parameters.

METHODS

We conducted a retrospective study on data collected on patients referred to our clinic for the evaluation of evacuation disorders. All patients were questioned for constipation, fecal incontinence, and irritable bowel syndrome and were assessed with dynamic perineal ultrasonography and conventional anorectal manometry.

RESULTS

Four hundred eighty-seven women were included in our study. Rectocele was diagnosed in 106 (22%) women, and rectocele diameter >2 cm in 93 (87%) women. Rectocele size was not significantly related to demographic data, parity, or patient's symptoms. The severity of the symptoms was not correlated to the size or to the position of the rectocele. The diagnosis of irritable bowel syndrome was neither related to the size of the rectocele. Rectocele location, occurrence of enterocele, and intussusception were not related to the size of the rectocele. Full evacuation of rectoceles was more common in small rectoceles (79% vs. 24%, p = 0.0001), and no evacuation was more common in large rectoceles (37% vs. 0, p = 0.01). Rectal hyposensitivity and anismus were not related to the size of the rectocele.

CONCLUSION

In conclusion, only the evacuation of rectoceles was correlated to the size of the rectoceles, but had no clinical significance. Other clinical, anatomical factors were also not associated to the size of the rectoceles. Rectoceles' size alone may not be an indication for surgery.

Efficacy of pelvic floor muscle training and hypopressive exercises for treating pelvic organ prolapse in women: randomized controlled trial

CONTEXT AND OBJECTIVE

Previous studies have shown that women with pelvic floor dysfunctions present decreased cross-sectional area (CSA) of the levator ani muscle. One way to assess the effects of training programs is to measure the CSA of the muscle, using ultrasonography. The aim here was to evaluate the efficacy of pelvic floor muscle training and hypopressive exercises for increasing the CSA of the levator ani muscle in women with pelvic organ prolapse.

DESIGN AND SETTING

Prospective randomized controlled trial at the Urogynecology outpatient clinic of Universidade Federal de São Paulo.

METHODS

Fifty-eight women with stage II pelvic organ prolapse were divided into three groups for physiotherapy: a pelvic floor muscle training group (GI); a hypopressive exercise group (GII); and a control group (GIII). The patients underwent transperineal ultrasonographic evaluation using a transducer of frequency 4-9 MHz. The (CSA) of the levator ani muscle was measured before physiotherapy and after 12 weeks of treatment.

RESULTS

The groups were homogeneous regarding age, number of pregnancies, number of vaginal deliveries, body mass index and hormonal status. Statistically significant differences in CSA were found in GI and GII from before to after the treatment (P < 0.001), but not in relation to GIII (P = 0.816).

CONCLUSIONS

The CSA of the levator ani muscle increased significantly with physiotherapy among the women with pelvic organ prolapse. Pelvic floor muscle training and hypopressive exercises produced similar improvements in the CSA of the levator ani muscle.

Multiparity causes uncoordinated activity of pelvic- and perineal-striated muscles and urodynamic changes in rabbits

Temporal and coordinated activation of pelvic- (pubococcygeous) and perineal- (bulbospongiosus and ischiocavernosus) striated muscles occurs during micturition in female rabbits. We have hypothesized that the coordinated activation of pelvic and perineal muscles is modified during the micturition of young multiparous rabbits. Young virgin and multiparous female chinchilla rabbits were used to simultaneously record cystometrograms and electromyograms of the pubococcygeous, ischocavernosus, and bulbospongiosus muscles. Bladder function was assessed using standard urodynamic variables. The temporal coordination of pelvic- and perineal-striated muscle activity was changed in multiparous rabbits. The cystometrogram recordings were different than those obtained from virgin rabbits, as seen in alterations of the threshold volume, the residual volume, the voiding duration, and the maximum pressure. In rabbits, we find that multiparity causes uncoordinated activity of pubococcygeous, ischiocavernosus, and bulbospongiosus muscles and modifies the urodynamics.

Influência da posição de parto vaginal nas variáveis obstétricas e neonatais de mulheres primíparas

OBJETIVOS: determinar a prevalência de fatores obstétricos associados à posição de parto vaginal (PPV) - vertical ou horizontal; investigar correlações entre PPV e fatores obstétricos, bem como sua influência sobre as características neonatais. MÉTODOS: foi realizado um estudo de corte transversal. A amostra foi composta por 176 mulheres primíparas que realizaram parto vaginal, entre julho/2006 e fevereiro/2007. Foi investigada a correlação entre PPV e as seguintes variáveis obstétricas: ocorrência e grau de laceração perineal espontânea, episiotomia, sutura perineal, uso de ocitocina e instrumentação cirúrgica. Os neonatos foram classificados quanto à idade gestacional, peso, estatura, perímetro cefálico e Apgar 1º e 5º minutos. Teste qui quadrado foi aplicado para investigar correlação entre PPV e variáveis obstétricas e o teste t-student para investigar a influência da PPV nas características neonatais. RESULTADOS: não foi observada correlação entre PPV e sutura perineal, laceração perineal, uso de ocitocina, episiotomia e utilização de instrumentação cirúrgica (uso de fórceps ou vácuo-extrator). Houve correlação entre PPV e episiotomia e maior prevalência de episiotomia na posição horizontal. Não houve influência da PPV nas características neonatais. CONCLUSÕES: houve maior ocorrência de episiotomia na posição de parto horizontal, embora ambas as posições de parto tenham sido satisfatórias para os neonatos.

Rectocele and intussusception: is there any coherence in symptoms or additional pelvic floor disorders?

BACKGROUND

Patients with a rectocele often suffer from such symptoms as obstructed defaecation, urine or stool incontinence and pain. The aim of this study was to assess other concomitant pelvic floor disorders and their influence on pelvic function.

METHODS

Included in the study were 37 female patients with a significant rectocele and defaecation disorder. Medical history and symptoms were analysed in terms of validated functional scores. All patients underwent open magnetic resonance defaecography (MRD) in a sitting position. Imaging was analysed for the presence and size of the rectocele, intussusception and other pelvic floor disorders.

RESULTS

Patients with a higher body mass index tended to have a larger rectocele, whereas age and vaginal birth did not correlate with the size of the rectocele. In 67.5% of the patients with a previously diagnosed rectocele, an intussusception was diagnosed on MRD. This group suffered from significantly worse urine incontinence (p=0.023) and from accessory enteroceles 64%, compared with 17% (p=0.013) for those with a simple rectocele. Patients with higher grade intussusception suffered more frequently from incontinence than from constipation.

CONCLUSION

Patients with a symptomatic rectocele frequently have other pelvic floor disorders that significantly influence the pattern of symptoms. Knowledge of all the afflictions is essential for determining the optimal treatment for each individual patient.

Stress urinary incontinence 3 years after pregnancy: correlation to mode of delivery and parity

The aim was to estimate the incidence of stress urinary incontinence 3 years after delivery and its correlation to mode of delivery and parity. A longitudinal cohort study was conducted with 120 women at the Antenatal Clinic at the State University of Campinas. There was a significant difference in the incidence of postpartum stress urinary incontinence (SUI) among patients with SUI during pregnancy (p > 0.0001). Women that were asymptomatic during pregnancy and had vaginal delivery developed SUI 2.4 times more frequently than after c-section (19.2% and 8.0%, respectively). The incidence of SUI after delivery dropped significantly in the primiparous (p = 0.0073) and multiparous 2-3 (p < 0.0001), but not in the multiparous with four or more deliveries (66.7% to 60.0%) (p = 0.5637). A significant correlation has been observed between parity and SUI (p = 0.0299). Pregnancy possibly predisposes to SUI 3 years after delivery as well as parity. No significant correlation has been demonstrated between mode of delivery and SUI.

Differences in morphology and contractility of the bulbospongiosus and pubococcygeus muscles in nulliparous and multiparous rabbits

In women, birth trauma can result in altered anatomy of supporting structures of the pelvic floor and in the development of urinary incontinence. The goal of this study was to investigate the association between parturition and the morphology and function of perineal and pelvic muscles in the female rabbit. In ten nulliparous and ten multiparous same-age females, we investigated morphological, histological (n = 5 females/group), and contractile characteristics (n = 5 females/group) of the perineal bulbospongiosus (Bsm) and the pelvic pubococcygeus (Pcm) muscles. Bsm and Pcm muscles of multiparous females were significantly lighter, they had a smaller cross-sectional fiber area, and developed significantly lower twitch and tetanic tension force in response to electrical stimulation than muscles of nulliparous females. In female rabbits, multiparity is associated with potentially pathological changes in the morphological and functional characteristics of these perineal and pelvic muscles, possibly as a result of stretching during parturition.

Factors associated with postpartum urinary/anal incontinence in primiparous women in Quebec

OBJECTIVE

To identify the factors associated with urinary incontinence (UI), anal incontinence (AI), and combined UI and AI (UI/AI) in primiparous women in Quebec at six months postpartum.

METHODS

A questionnaire was mailed to 2492 primiparous women at six months postpartum to collect data on incontinence status, sociodemographic characteristics, elimination habits, lifestyle, and severity index scales. Obstetric characteristics were obtained via Quebec's Med-Echo databank. Pearson chi-square, t test, analysis of variance, univariate regression, and stepwise modelling techniques were used for data analysis.

RESULTS

The prevalence of UI in responders was 29.6%, of AI, 20.6%, and of combined UI/AI, 10.4%. Significant adjusted odds ratios were (1) for UI, English spoken (2.04 [95% confidence intervals 1.13-3.69]) and shoulder dystocia (2.90 [1.09-7.69]); (2) for AI, age > 35 years (2.13 [1.12-4.03]), duration of second stage of labour (1.67 [1.11-2.51]), and third or fourth degree tears (4.00 [2.32-6.89]); and (3) for UI and AI, age (2.00 [1.04-3.83]), English spoken (2.55 [1.25-5.19]), shoulder dystocia (4.91 [1.76-13.71]), instrumental delivery (2.28 [1.30-3.99]), third or fourth degree tears (3.58 [1.95-6.57]), and episiotomy (2.24 [1.162-4.33]). Caesarean section was associated with less UI (0.45 [0.28-0.72]), and smoking was associated with less AI (0.38 [0.19-0.76]).

CONCLUSION

Combined UI/AI is associated with several obstetrical factors. The association of UI and AI is observed more frequently after complicated delivery (requiring the application of forceps) or involving perineal damage and episiotomy. As most of the identified factors are modifiable, a preventive treatment policy is advisable.

Obstetric-induced incontinence: A black hole of preventable morbidity

There is a detailed literature comprising clinical and anorectal physiological studies linking faecal incontinence to vaginal delivery. Specific risk factors are high infant birthweight, forceps delivery and prolonged second stage of labour. The onset of symptoms may be delayed for many years. Faecal incontinence occurs in more than 10% of adult females and urinary incontinence in about a third of multiparous women. This places a very large economic burden on the Australian health system. A conservative estimate for overall management of incontinence would be in excess of $A700 million but the actual amount is unknown. Preventative measures for avoiding pelvic floor injuries need to be established, and safe obstetric practice needs to be redefined in the light of current knowledge about incontinence. Outcome measures for safe birthing should not only include infant and maternal mortality and infant morbidity, but should also include the long-term effects of vaginal delivery on the pelvic floor, particularly urinary and faecal incontinence. Several state reports and one federal senate report on safe birthing have been lacking in this area. The safety of birthing centres and home birthing needs to be examined to provide birthing mothers with complete and appropriate information about safety in order that they may consider their options. Appropriate Caesarean section rates for optimal birthing safety are unknown and need to be re-examined. Calls for overall reduction in Caesarean section rates in Australia are inappropriate and cannot be justified until the effects of pelvic floor injury are added to the overall assessment.

Predicting operative delivery

OBJECTIVE

Unplanned operative delivery (vaginal or abdominal) is associated with maternal anxiety, maternal and neonatal morbidity and increased resource use. We aimed to identify potential predictors for emergency operative delivery.

METHODS

This was a prospective observational study of 202 nulliparous women in a tertiary antenatal unit between 36 and 40 weeks' gestation. The assessment included an interview, a vaginal examination for Bishop score (optional), and a translabial ultrasound examination performed with the woman in a supine position and after voiding to determine cervical length, bladder position on Valsalva, and fetal head engagement. Clinical data were obtained from the institutional obstetric database and patient records.

RESULTS

In the late third trimester, body mass index (P = 0.016), maternal age at due date (P < 0.0001), history of Cesarean section in first-degree relatives (P = 0.009), Bishop score (P = 0.0004), cervical length (P = 0.001), bladder position on Valsalva (P = 0.003) and head engagement (P < 0.0001) were significantly associated with delivery mode. On multivariate logistic regression analysis, the best model for predicting normal vaginal delivery contained maternal age, history of Cesarean section, Bishop score and bladder position on Valsalva and had excellent ability to discriminate between normal vaginal delivery and operative delivery (c = 0.85). The model with the best ability to discriminate between vaginal delivery and Cesarean section contained the same parameters plus body mass index; this model performed even better (c = 0.87).

CONCLUSIONS

Identification of women at increased risk of operative delivery appears feasible. A combination of clinical and ultrasound variables yielded a model that is likely to predict delivery mode accurately in up to 87% of cases. Such a model may become useful as an entry criterion for intervention trials in women at low or very high risk of operative delivery.

Levator Trauma After Vaginal Delivery

OBJECTIVE

To date, the evidence on pelvic floor injury in labor remains sketchy due to a lack of prospective studies comparing pelvic floor imaging before and after childbirth. We intended to define the incidence of major trauma to the pubovisceral muscle.

METHODS

A total of 61 nulliparous women were seen at 36-40 weeks of gestation in a prospective observational study. The assessment included an interview and 3-dimensional translabial ultrasound and was repeated 2-6 months postpartum.

RESULTS

Fifty women (82%) were seen postpartum. Of the 39 women delivered vaginally, levator avulsion was diagnosed in 14 (36%, 95% confidence interval 21-51%). Among those delivered vaginally, there were associations with higher maternal age (P = .10), vaginal operative delivery (P = .07), and worsened stress incontinence postpartum (P = .02).

CONCLUSIONS

Avulsion of the inferomedial aspects of the levator ani from the pelvic sidewall occurred in approximately one third of all women delivered vaginally and was associated with stress incontinence 3 months after childbirth.