Contribution of the second stage of labour to pelvic floor dysfunction: a prospective cohort comparison of nulliparous women

Abstract

Objective Maternal expulsive efforts are thought to damage the pelvic floor. We aimed to compare pelvic floor function and anatomy between women who delivered vaginally (VB) versus cesarean (CD) without entering the second stage of labor. Design Prospective cohort Setting University Hospital Midwifery practice Population Nulliparas Methods Pregnant nulliparas were recruited during pregnancy and women who underwent CD prior to the 2nd stage of labor at birth were recruited immediately postpartum. Both groups were prospectively followed to 6 months postpartum. Main Outcome Measures POPQ, perineal ultrasound(U/S) and Paper Towel Test(PTT), an objective measure of stress incontinence; Incontinence Severity Index(ISI), Pelvic Floor Impact Questionnaire(PFIQ-7), Wexner Fecal Incontinence Scale(W) and Female Sexual Function Index(FSFI) Results 336/448(75%)VB and 138/224(62%)CD followed up. The VB group was younger (23.9+/−4.9 vs 26.6+/−6.1 years, P<.001) and less overweight/obese (38 vs 56%, P<.001); baseline functional measures were similar(all P>.05). At followup, urinary incontinence (UI)(55 vs 46% ISI>0, P=.10), fecal incontinence(FI) (8 vs 13% FI on W, P = .12), sexual activity rates(88 vs 92%, P=.18) and PFIQ-7 scores were similar. Positive PTT tests(17 vs 6%, P=.002) and ≥Stage 2 prolapse (22 vs 15%, P=.03) were higher with VB; differences were limited to points Aa and Ba. U/S findings were not different between groups. Stepwise multivariate analyses controlling for age, BMI, and non-Hispanic White race for prolapse of points Aa and Ba did not alter conclusions (all P <.004). Conclusions VB resulted in prolapse changes and objective UI, but did not result in increased self-report pelvic floor dysfunction at 6 months postpartum compared to women who delivered by CD without the second stage of labor. The second stage of labor has a modest effect on postpartum pelvic floor function.

The relationship of 3-D translabial ultrasound anal sphincter complex measurements to postpartum anal and fecal incontinence

“…As reported previously, 10,14 there was a low rate of vacuum deliveries (25 women, 6%), forceps delivery (one woman, 0.2%), episiotomy (8 women, 2%), and third or fourth degree lacerations (22 women, 5%) among the women who had a VB, and only 24 women entered the second stage of labor before delivering by a CD. There were 433 women (62%) who presented for US imaging 6 months postpartum, with 423 (299 VB and 124 CD) having full imaging of the sphincters.…”

“…Methods of the parent study and ultrasound findings have been reported in prior publications. 10,14 One expert sonologist (RH), three female pelvic medicine fellows, and one female pelvic medicine attending (RG) performed and interpreted all the imaging, with previous a publication reporting on the inter-rater reliability of this group. 9 Patients underwent both translabial (TL-US) and endoanal ultrasound (EA-US) at the same time point as part of the parent study, with comparison between these imaging modalities published previously, 15 but this manuscript concerns itself with the TL-US imaging.…”

Postpartum stress urinary incontinence, is it related to vaginal delivery?

“…Review of the available evidence allows the assumption that prolonged second-stage labor and vaginal delivery can both damage the pelvic floor [24,25]. One study shows that nearly one-third of women have levator ani denervation after their first delivery, although many recover by 6 months postpartum [26].…”

Anal sphincter complex: 2D and 3D endoanal and translabial ultrasound measurement variation in normal postpartum measurements

“…13,17,18 Labor and maternal characteristics were gathered at birth and included detailed examination of all lacerations to the genital tract sustained during delivery. Women with a second degree or more severe perineal laceration were evaluated by a second examiner to ensure that lacerations were graded appropriately.…”