Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
International Urogynecology Journal
Published in: International Urogynecology Journal 6/2019

01-06-2019 | Original Article

Delivery mode and the risk of levator muscle avulsion: a meta-analysis

Authors: Talia Friedman, Guy D. Eslick, Hans Peter Dietz

Published in: International Urogynecology Journal | Issue 6/2019

Login to get access

Abstract

Introduction and hypothesis

Female pelvic organ prolapse (POP) is a common condition, with a lifetime risk for surgery of 10–20%. Pregnancy and childbirth are the commonest modifiable risk factors for POP, and avulsion of the levator ani muscle is likely to be an etiological factor. Avulsion is more common in instrumental delivery. However, we were unable to identify a meta-analysis on this issue. Our aim was to perform a systemic review and quantitative meta-analysis of the prevalence of avulsion relative to delivery mode.

Methods

Four electronic databases (MEDLINE, PubMed, Embase, and Google Scholar) were searched for studies published between 1991 and 1 October 2018 without language restrictions.

Results

Twenty studies met inclusion criteria, and 14 were prospective. Seventeen used sonographic techniques; three were magnetic resonance (MR) studies. For this review, three comparisons were performed: forceps vs. vacuum (9 studies), forceps vs. normal vaginal delivery (NVD) (12 studies), and vacuum vs. NVD (12 studies). The first meta-analysis showed an increased risk for avulsion following forceps compared with vacuum, with an odds ratio (OR) of 4.57 and confidence interval (CI) 3.21–6.51, p < 0.001. The second showed an increased risk for avulsion following forceps compared with NVD, with an OR of 6.94 (4.93–9.78), p < 0.001. The third showed no significant increased risk for avulsion following vacuum compared with NVD, with an OR of 1.31 (1.00–1.72), p = 0.051.

Conclusions

Forceps is a strong risk factor for avulsion, with an OR of 6.94 (4.93–9.78) compared with NVD and an OR of 4.57 (3.21–6.51) compared with vacuum birth.
Literature
1.
Fritel X, Varnoux N, Zins M, Breart G, Ringa V. Symptomatic pelvic organ prolapse at midlife, quality of life, and risk factors. Obstet Gynecol. 2009;113:609.CrossRefPubMedPubMedCentral
2.
Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89:501–6.CrossRefPubMed
3.
Smith FJ, Holman CAJ, Moorin RE, Tsokos N. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol. 2010;116:1096–100.CrossRefPubMed
4.
Gyhagen M, Bullarbo M, Nielsen T, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG Int J Obstet Gynaecol. 2013;120:152–60.CrossRef
5.
Dietz H, Simpson J. Levator trauma is associated with pelvic organ prolapse. BJOG Int J Obstet Gynaecol. 2008;115:979–84.CrossRef
6.
7.
Shek K, Dietz H. Intrapartum risk factors for levator trauma. BJOG Int J Obstet Gynaecol. 2010;117:1485–92.CrossRef
8.
Chan S, Cheung R, Yiu A, et al. Prevalence of levator ani muscle injury in Chinese women after first delivery. Ultrasound Obstet Gynecol. 2012;39:704–9.CrossRefPubMed
9.
Cassadó J, Pessarrodona A, Rodriguez-Carballeira M, et al. Does episiotomy protect against injury of the levator ani muscle in normal vaginal delivery? Neurourol Urodyn. 2014;33:1212–6.CrossRefPubMed
10.
11.
12.
Higgins J, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses [journal article as teaching resource, deposited by John Flynn]. Br Med J. 2003;327:557–60.CrossRef
13.
14.
Orwin RG. A fail-safe N for effect size in meta-analysis. J Educ Stat. 1983;8:157–9.
15.
Kearney R, Miller JM, Ashton-Miller JA, DeLancey JO. Obstetrical factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol. 2006;107:144.CrossRefPubMedPubMedCentral
16.
Dietz HP, Simpson JM. Does delayed child-bearing increase the risk of levator injury in labour? Aust N Z J Obstet Gynaecol. 2007;47:491–5.CrossRefPubMed
17.
Valsky DV, Lipschuetz M, Bord A, et al. Fetal head circumference and length of second stage of labor are risk factors for levator ani muscle injury, diagnosed by 3-dimensional transperineal ultrasound in primiparous women. Am J Obstet Gynecol. 2009;201:91.e1–7.CrossRef
18.
Kearney R, Fitzpatrick M, Brennan S, et al. Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery. Int J Gynecol Obstet. 2010;111:19–22.CrossRef
19.
Dietz HP, Kirby A. Modelling the likelihood of levator avulsion in a urogynaecological population. Aust N Z J Obstet Gynaecol. 2010;50:268–72.CrossRefPubMed
20.
Garriga JC, Isern AP, Pons ME, Retamal MD, Fabregas AF, Rodriguez-Carballeira M. Tridimensional sonographic anatomical changes on pelvic floor muscle according to the type of delivery. Int Urogynecol J. 2011;22:1011–8.CrossRef
21.
Cassadó Garriga J, Pessarrodona Isern A, Espuna Pons M, et al. Four-dimensional sonographic evaluation of avulsion of the levator ani according to delivery mode. Ultrasound Obstet Gynecol. 2011;38:701–6.CrossRefPubMed
22.
Albrich S, Laterza R, Skala C, Salvatore S, Koelbl H, Naumann G. Impact of mode of delivery on levator morphology: a prospective observational study with three-dimensional ultrasound early in the postpartum period. BJOG Int J Obstet Gynaecol. 2012;119:51–61.CrossRef
23.
Eisenberg V, Brecher S, Kalter A, Achiron R, Schiff E, Alcalay M. OP34. 06: the birthmark of instrumental deliveries. Ultrasound Obstet Gynecol. 2011;38:153–4.
24.
Araujo Júnior E, de Freitas RCM, Di Bella ZIK, et al. Assessment of pelvic floor by three-dimensional-ultrasound in primiparous women according to delivery mode: initial experience from a single reference service in Brazil. Rev Bras Ginecol Obstet. 2013;35:117–22.CrossRefPubMed
25.
Delft K, Thakar R, Sultan A, Schwertner-Tiepelmann N, Kluivers K. Levator ani muscle avulsion during childbirth: a risk prediction model. BJOG Int J Obstet Gynaecol. 2014;121:1155–63.CrossRef
26.
Low LK, Zielinski R, Tao Y, Galecki A, Brandon CJ, Miller JM. Predicting birth-related levator ani tear severity in primiparous women: evaluating maternal recovery from labor and delivery (EMRLD study). Open J Obstet Gynecol. 2014;4:266.CrossRefPubMedPubMedCentral
27.
Chung M, Wan O, Cheung R, Chung T, Chan S. Prevalence of levator ani muscle injury and health-related quality of life in primiparous Chinese women after instrumental delivery. Ultrasound Obstet Gynecol. 2015;45:728–33.CrossRefPubMed
28.
Durnea C, O’reilly B, Khashan A, et al. Status of the pelvic floor in young primiparous women. Ultrasound Obstet Gynecol. 2015;46:356–62.CrossRefPubMed
29.
Caudwell-Hall J, Kamisan Atan I, Martin A, et al. OC09. 05: intrapartum predictors of pelvic floor trauma. Ultrasound Obstet Gynecol. 2014;44:21–2.CrossRef
30.
Memon HU, Blomquist JL, Dietz HP, Pierce CB, Weinstein MM, Handa VL. Comparison of Levator Ani muscle avulsion injury after forceps and vacuum-assisted vaginal childbirth. Obstet Gynecol. 2015;125:1080.CrossRefPubMedPubMedCentral
31.
Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen K. Forceps delivery is associated with increased risk of pelvic organ prolapse and muscle trauma: a cross-sectional study 16–24 years after first delivery. Ultrasound Obstet Gynecol. 2015;46:487–95.CrossRefPubMed
32.
Michalec I, Simetka O, Navratilova M, et al. Vacuum-assisted vaginal delivery and levator ani avulsion in primiparous women. J Matern Fetal Neonatal Med. 2016;29:2715–8.PubMed
33.
Valsky DV, Cohen SM, Lipschuetz M, et al. Third-or fourth-degree intrapartum anal sphincter tears are associated with levator ani avulsion in primiparas. J Ultrasound Med. 2016;35:709–15.CrossRefPubMed
34.
DeLancey JO. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol. 2002;187:93–8.CrossRefPubMed
35.
Dietz H. Ultrasound imaging of the pelvic floor. Part II: three-dimensional or volume imaging. Ultrasound Obstet Gynecol. 2004;23:615–25.CrossRefPubMed
36.
Brækken IH, Majida M, Ellstrøm-Engh M, Dietz HP, Umek W, Bø K. Test–retest and intra-observer repeatability of two-, three-and four-dimensional perineal ultrasound of pelvic floor muscle anatomy and function. Int Urogynecol J. 2008;19:227–35.CrossRef
37.
Zhuang RR, Song YF, Chen ZQ, et al. Levator avulsion using a tomographic ultrasound and magnetic resonance–based model. Am J Obstet Gynecol. 2011;205:232.e1–8.CrossRef
38.
Dietz H. Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol. 2007;29:329–34.CrossRefPubMed
39.
Weishaupt J, Caudwell Hall J, Dietz HP. Does the increased space requirement explain the high risk of levator avulsion in Forceps delivery? 15th Pelvic Floor Symposium of the Australasian Gynaecological Endoscopy and Surgery Society, Adelaide, 2014.
40.
41.
Abdel-Fattah M, Familusi A, Fielding S, Ford J, Bhattacharya S. Primary and repeat surgical treatment for female pelvic organ prolapse and incontinence in parous women in the UK: a register linkage study. BMJ Open. 2011;1:e000206.CrossRefPubMedPubMedCentral
42.
Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Muñoz A. Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth. Obstet Gynecol. 2011;118:777.CrossRefPubMedPubMedCentral
43.
Løwenstein E, Ottesen B, Gimbel H. Response to the letter to the editor by HP Dietz. Int Urogynecol J. 2015;26:1091.CrossRefPubMed
44.
Løwenstein E, Ottesen B, Gimbel H. Incidence and lifetime risk of pelvic organ prolapse surgery in Denmark from 1977 to 2009. Int Urogynecol J. 2015;26:49–55.CrossRefPubMed
45.
Turel F, Caagbay D, Dietz H. OP28. 04: the prevalence of major birth trauma in Nepali women. Ultrasound Obstet Gynecol. 2017;50:140.CrossRef
Metadata
Title
Delivery mode and the risk of levator muscle avulsion: a meta-analysis
Authors
Talia Friedman
Guy D. Eslick
Hans Peter Dietz
Publication date
01-06-2019
Publisher
Springer International Publishing
Published in
International Urogynecology Journal / Issue 6/2019
Print ISSN: 0937-3462
Electronic ISSN: 1433-3023
DOI
https://doi.org/10.1007/s00192-018-3827-8

Other articles of this Issue 6/2019

International Urogynecology Journal 6/2019 Go to the issue

Original Article

Signs of damage in pelvic floor muscles at the end of pregnancy in rabbits

Original Article

Learning about pelvic floor muscle exercises before and during pregnancy: a cross-sectional study

Original Article

Effects of perineal preparation techniques on tissue extensibility and muscle strength: a pilot study

Original Article

Urinary incontinence between 12 and 24 months postpartum: a cross-sectional study nested in a Brazilian cohort from two cities with different socioeconomic characteristics

Original Article

Single prior caesarean section and risk of anal sphincter injury

Original Article

Parity: a risk factor for decreased pelvic floor muscle strength and endurance in middle-aged women