Top

International Urogynecology Journal

Published in:

01-10-2009 | Original Article

Pubococcygeus–puborectalis trauma after forceps delivery: evaluation of the levator ani muscle with 3D/4D ultrasound

Authors: Ladislav Krofta, Michal Otčenášek, Eva Kašíková, Jaroslav Feyereisl

Published in: International Urogynecology Journal | Issue 10/2009

Abstract

Introduction and hypothesis

This study seeks to assess the effects of forceps-assisted delivery on the levator hiatus.

Methods

Seventy-six women were investigated 12 months after forceps-assisted delivery. Introital three-/four-dimensional ultrasound measured volumes at rest and during the Valsalva maneuver. Morphological parameters analyzed were angle gamma, hiatal area, pubovisceral angle, and continuity between the muscle and pelvic sidewall. Avulsion was diagnosed by loss of continuity.

Results

Forty-eight women had avulsion injuries, 23 had bilateral, and 25 had unilateral. Bilateral avulsion increased hiatal area during straining and at rest and was associated with changes in bladder neck position at rest. Unilateral avulsion injury was associated with a higher pubovisceral angle on the side of the avulsion.

Conclusion

Forceps-assisted vaginal delivery is associated with levator ani injury. Avulsion of the pubovisceral muscle seems more common after forceps delivery than after spontaneous vaginal delivery. Avulsion alters hiatal shape and area and influences the position and mobility of the anterior compartment.

Steensma AB, Dietz HP (2004) 3D pelvic floor ultrasound in the assessment of the levator ani muscle complex. Ultrasound Obstet Gynecol 24:258CrossRef

DeLancey JO, Kearney R, Chou Q, Speights S, Binno S (2003) The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 101:46–53PubMedCrossRef

Lien KC, Mooney B, DeLancey JO, Ashton-Miller JA (2004) Levator ani muscle stretch inducted by simulated vaginal birth. Obstet Gynecol 103:31–40PubMed

Mant J, Painter R, Vessey M (2006) Epidemiology of genital prolapse: observations from the Oxford Family Planning Association study. Br J Obstet Gynaecol 113:225–230

Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S (2001) Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPICONT study. Obstet Gynecol 98:1004–1010PubMedCrossRef

Patel DA, Xu X, Thomason AD, Ransom SB, Ivy JS, DeLancey JO (2006) Childbirth and pelvic floor dysfunction: an epidemiologic approach to assessing prevention opportunities at delivery. Am J Obstet Gynecol 195:23–28PubMedCrossRef

Hoyte L, Schierlitz L, Zou K, Flesh G, Fielding J (2001) Two- and 3-dimensional MRI comparison of levator ani structure, volume, and integrity in women with stress incontinence and prolapse. Am J Obstet Gynecol 185:11–19PubMedCrossRef

Dietz HP, Lanzarone V (2005) Levator trauma after vaginal delivery Obstet Gynecol 106:707–712

Dietz HP (2007) Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol 29:329–334PubMedCrossRef

10.

Otcenasek M, Krofta L, Baca V et al (2007) Bilateral avulsion of the puborectal muscle: magnetic resonance imaging-based three-dimensional reconstruction and comparison with a model of a healthy nulliparous woman. Ultrasound Obstet Gynecol 29:692–696PubMedCrossRef

11.

DeLancey JO (2005) The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment. Am J Obstet Gynecol 192:1488–1495PubMedCrossRef

12.

Kearney R, Miller J, Ashton-Miller J, Delancey JO (2006) Obstetric factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol 107:144–149PubMed

13.

Dietz HP, Shek C, Clarke B (2005) Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol 25:580–585PubMedCrossRef

14.

Shrout PE, Fleiss JL (1979) Intraclass correlation: uses in assessing rater reliability. Psychological Bulletin 86:420–428PubMedCrossRef

15.

Hervé A (2007) The Bonferonni and Šidák corrections for multiple comparisons. In: Salkind Neil (ed) Encyclopedia of measurement and statistics. Sage, Thousand Oaks, CA

16.

Braekken IH, Majida M, Ellstrom Engh M, Dietz HP, Umek W, Bo K (2008) Test- retest and intra-observer repeatability of two-, three- and four- dimensional perineal ultrasound of pelvic floor muscle anatomy and function. Int Urogynecol J 19:227–235CrossRef

17.

Guaderrama N, Liu J, Nager C, Pretorius D, Sheean G, Kassab G et al (2006) Evidence for the innervation of pelvic floor muscles by the pudendal nerve. Obstet Gynecol 106(4):774–781

18.

Dietz H, Simpson J (2007) Does delayed childbearing increase the risk of levator injury in labour? Aust NZ J Obstet Gynaecol 47:491–495CrossRef

19.

Dietz HP, Wilson PD (1999) The influence of bladder volume on the position and mobility of the urethrovesical junction. Int Urogynecol J 10:3–6CrossRef

20.

Tunn R, Schaer G, Peschers U, Bader W, Gauruder- Burmester A, Hanzal E et al (2005) Updated recommendations on ultrasonography in urogynecology. Int Urogynecol J 16:236–241CrossRef

21.

Dietz HP (2004) Ultrasound imaging of the pelvic floor. Part I: two-dimensional aspects. Ultrasound Obstet Gynecol 23(1):80–92 [Review] [86 refs]PubMedCrossRef

22.

Kruger JA, Heap SW, Murphy BA, Dietz HP (2008) Pelvic floor function in nulliparous women imaged using three-dimensional ultrasound and magnetic resonance imaging. Obstet Gynecol 111:631–638PubMed

23.

Yang JM, Yang SH, Huang WC (2006) Biometry of the pubovisceral muscle and levator hiatus in nulliparous Chinese women. Ultrasound Obstet Gynecol 28:710–716PubMedCrossRef

24.

Krueger JA, Dietz HP (2007) Pelvic floor function in elite nulliparous athletes. Ultrasound Obstet Gynecol 30:81–85CrossRef

25.

DeLancey JO, Hurd WW (1998) Size of the urogenital hiatus in the levator ani muscles in normal women and women with pelvic organ prolapse. Obstet Gynecol 91:364–368PubMedCrossRef

26.

DeLancey JO (2001) Anatomy. In: Cardovo L, Staskin D (eds) Textbook of female urology and urogynaecology. Isis Medical Media, London, UK, pp 112–124

27.

Dietz HP, Steensma AB (2006) The prevalence of major abnormalities of the levator ani in urogynaecological patients. Br J Obstet Gynaecol 113:225–230

28.

Lien KC, Morgan DM, DeLancey JO, Ashton-Miller JA (2005) Pudendal nerve stretch during vaginal birth: a 3D computer simulation. Am J Obstet Gynecol 192:1669–1676PubMedCrossRef

29.

Gainey HL (1955) Postpartum observation of pelvic tissue damage: further studies. Am J Obstet Gynecol 70:800–807PubMed

30.

Gainey HL (1943) Postpartum observation of pelvic tissue damage. Am J Obstet Gynecol 45:457–466

31.

Ranney B (1990) Decreasing numbers of patients for vaginal hysterectomy and plasty. S D J Med 43:7–12PubMed

Title: Pubococcygeus–puborectalis trauma after forceps delivery: evaluation of the levator ani muscle with 3D/4D ultrasound
Authors: Ladislav Krofta
Michal Otčenášek
Eva Kašíková
Jaroslav Feyereisl
Publication date: 01-10-2009
Publisher: Springer-Verlag
Published in: International Urogynecology Journal / Issue 10/2009
Print ISSN: 0937-3462
Electronic ISSN: 1433-3023
DOI: https://doi.org/10.1007/s00192-009-0837-6

At a glance: The STEP trials

Springer Medicine

Pubococcygeus–puborectalis trauma after forceps delivery: evaluation of the levator ani muscle with 3D/4D ultrasound

Abstract

Introduction and hypothesis

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction and hypothesis

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 10/2009

Videourodynamic evaluation of urge syndrome following pubovaginal sling procedure for stress urinary incontinence in women

Conservative versus surgical management of prolapse: what dictates patient choice?

Evaluating patient learning after an educational program for women with incontinence and pelvic organ prolapse

Accuracy of recall in quality-of-life assessment among women operated on for stress urinary incontinence

Experience with a low-pressure colonic pouch (Mainz II) urinary diversion for irreparable vesicovaginal fistula and bladder extrophy in East Africa

Effect of pelvic floor muscle exercises in the treatment of urinary incontinence during pregnancy and the postpartum period