Neuropathic injury to the levator ani occurs in 1 in 4 primiparous women

Weidner, Alison C.; Jamison, Margaret G.; Branham, V.; South, Mary M.T.; Borawski, Kristy M.; Romero, Audrey A.

doi:10.1016/j.ajog.2006.06.062

Cited by 54 publications

(34 citation statements)

References 17 publications

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“…52 A recent report reveals that there is no difference in nerve injury between operative vaginal deliveries, spontaneous vaginal deliveries, or cesarean section in labor with all modes resulting in about 25% having some injury. 53 Recently the concept of the levator muscles being solely innervated by the pudendal nerve has been challenged by Barber et al 54 showing some direct innervation from the sacral nerves. If a significant amount of innervation comes from the sacral nerves directly, damage from pressure from the fetal head could be evident without labor, thus explaining why cesarean section is not completely protective.…”

Section: Pelvic Floor Function and Association With Delivery Traumamentioning

confidence: 99%

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Operative Vaginal Delivery: A Cause of Birth Injury or Is It?

Towner

Ciotti²

2007

Clinical Obstetrics &Amp; Gynecology

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Operative vaginal delivery has been maligned since the days of W.J. Little with the word "forceps" becoming nearly synonymous with "Birth Injury" and "Cerebral Palsy." However in his presentation to the Obstetrical Society of London in 1861, Little's emphasis was on difficult labors being the culprit in subsequent disabilities in the offspring. Instrumented deliveries in that era were the end result of a long, obstructed labor performed for maternal benefit and to avoid a destructive procedure to the fetus thus allowing a chance at life. If there had been a normal progress in labor, operative assistance for delivery would not have been needed. Thus, was it the instrument or the obstructed labor that led to fetal injury? In this article, we will review what injuries to the fetus and the mother can be directly attributable to the instrument. We will explore the processes of labor, conduct of labor management, and concurrent fetal factors that can modulate the occurrence of birth trauma. Evidence regarding inexperience and improper use as contributing to injury will also be explored.

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Section: Pelvic Floor Function and Association With Delivery Traumamentioning

confidence: 99%

“…Studies that have evaluated nerve conduction have shown similar levels of nerve damage from assisted and unassisted deliveries 53. …”

mentioning

confidence: 97%

Operative Vaginal Delivery: A Cause of Birth Injury or Is It?

Towner

Ciotti²

2007

Clinical Obstetrics &Amp; Gynecology

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“…Women with known pelvic organ prolapse are more likely (53% vs. 16% for normal controls) to show this same pattern of levator ani injury [4]. Competing hypotheses about injury mechanism are unresolved and include 1) excessive muscle stretch [3] vs. 2) nerve injury [5] vs. 3) compression from the baby’s head resulting in ischemia and reperfusion injury [6]. …”

Section: Introductionmentioning

confidence: 99%

MRI Findings in Patients Considered High Risk for Pelvic Floor Injury Studied Serially After Vaginal Childbirth

Miller

Brandon

Jacobson

et al. 2010

American Journal of Roentgenology

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Objective To characterize pelvic floor injury after vaginal childbirth with serial MRI. Methods 3T MR images were obtained early (1-month) and late (7-months) after childbirth in 19 women with risk factors for pelvic floor injury. All received multiplanar intermediate-weighted sequences and 11 had fluid sensitive sequences. MR images were evaluated for levator edema and tears, and pubic abnormalities. Results Three had unilateral high-grade tears, three had unilateral low grade tears, one had bilateral high and low-grade tears of the levator ani muscles. All tears were focal at the pubis. Levator edema was present in all on initial imaging and resolved at follow-up. Six had bone marrow edema; five with fracture line. None showed a pattern indicating nerve damage separate from muscle tears. Conclusion MRI showed focal levator ani muscle tears at the pubis with bone marrow edema and fracture in patients at risk for pelvic floor injury.

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“…7 Electromyography of the levator ani muscle has shown neuropathic injury in one quarter of women after a single VD, though that study did not correlate the observed changes to pelvic floor function. 8 The urethral rhabdomyosphincter is too small for reliable electromyography; nonetheless, a reduction in urethral closure pressure after vaginal delivery has been shown, though not confirmed by other studies. 9 There should be no doubt that VD leads to immediate measurable damage, but only in a minority of the cases does this lead to immediate loss of function or symptoms.…”

Section: The Deleterious Effects Of Childbirth On the Pelvic Floormentioning

confidence: 99%

The impact of vaginal delivery on pelvic floor function – delivery as a time point for secondary prevention

Callewaert

Albersen

Janssen

et al. 2015

BJOG

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Please cite this paper as: Callewaert G, Albersen M, Janssen K, Damaser MS, Van Mieghem T, van der Vaart CH, Deprest J. The impact of vaginal delivery on pelvic floor function -delivery as a time point for secondary prevention: a commentary. BJOG 2016;123:678-681. Pelvic floor disorders (PFD) cover a spectrum of conditions, including pelvic organ prolapse (POP), urinary (UI) and fecal incontinence (FI). Vaginal birth is considered the leading risk factor. Passage of the fetal head is associated with exceptional forces on and stretching of the pelvic floor. Since vaginal delivery occurs under medical supervision, it is the ideal moment for preventive action.1 Measures could be initiated promptly, restoring the damage caused by vaginal delivery to prevent PFD from developing. One of the experimental strategies currently being explored is the use of stem cells to boost the innate healing response. Though apparently futuristic, the experimental evidence of its efficacy is accumulating. The deleterious effects of childbirth on the pelvic floorAlthough PFD is a multifactorial disease there is ample evidence that vaginal delivery (VD) causes pelvic floor trauma. These mechanisms are believed to be essentially mechanical and ischaemic in nature. The impact of VD on the anal sphincter has been long recognised. The prevalence of anal sphincter injury following VD as visible on ultrasound is as high as 24.5% in prospective studies.2 VD makes the pubococcygeal muscles stretch to at least twice their initial length.3 In experimental conditions in non-pregnant rabbits, stretching a skeletal muscle by half its length is already sufficient to cause function loss. 4 Whether this threshold also applies to the levator and the peripartum is uncertain, but it should be no surprise that there is clinically demonstrable levator trauma following VD in one out of three women. 5VD also damages the innervation of the pelvic floor. The anal sphincter as well as the levator plate innervation may be injured by stretch, although for levator injury, compression and ischaemia may also contribute. 6 As a consequence, 40% of women display increased pudendal nerve terminal motor latency, although this recovers in two-thirds of women.7 Electromyography of the levator ani muscle has shown neuropathic injury in one quarter of women after a single VD, though that study did not correlate the observed changes to pelvic floor function. 8The urethral rhabdomyosphincter is too small for reliable electromyography; nonetheless, a reduction in urethral closure pressure after vaginal delivery has been shown, though not confirmed by other studies. 9There should be no doubt that VD leads to immediate measurable damage, but only in a minority of the cases does this lead to immediate loss of function or symptoms. Over time, however, up to half of women who delivered vaginally display PFD, as recently documented in several large studies. By a unique combination correlating obstetrical factors concerning first delivery and long-term anatomical and functional outc...

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Neuropathic injury to the levator ani occurs in 1 in 4 primiparous women

Cited by 54 publications

References 17 publications

Operative Vaginal Delivery: A Cause of Birth Injury or Is It?

Operative Vaginal Delivery: A Cause of Birth Injury or Is It?

MRI Findings in Patients Considered High Risk for Pelvic Floor Injury Studied Serially After Vaginal Childbirth

The impact of vaginal delivery on pelvic floor function – delivery as a time point for secondary prevention

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