Vacuum-assisted vaginal delivery does not significantly contribute to the higher incidence of levator ani avulsion

Česká verzia

Authors: I. Michalec ^1,2; M. Navratilova ¹; M. Tomanová ¹ ; M. Kacerovský ³; D. Šalounová ⁴; M. Procházka ^5,6; O. Šimetka ^1,2
Authors place of work: Porodnicko-gynekologická klinika FN, Ostrava, přednosta doc. MUDr. V. Unzeitig, CSc. ¹; Katedra chirugických oborů LF OU, Ostrava, vedoucí doc. MUDr. P. Zonča, Ph. D., FRCS ²; Porodnicko-gynekologická klinika LF UK a FN, Hradec Králové, přednosta doc. MUDr. J. Špaček, Ph. D., IFEPAG ³; Katedra matematických metod v ekonomice Ekonomické fakulty Vysoké školy báňské – Technické univerzity Ostrava, vedoucí útvaru doc. RNDr. D. Šalounová, Ph. D. ⁴; Porodnicko-gynekologická klinika LF UP a FN, Olomouc, přednosta prof. MUDr. R. Pilka, Ph. D. ⁵; Ústav porodní asistence FZV LF UP, Olomouc, přednosta doc. MUDr. M. Procházka, Ph. D. ⁶
Published in the journal: Ceska Gynekol 2015; 80(1): 37-41

Summary

Objective:
To draw a comparison between spontaneous vaginal delivery and vacuum-assisted vaginal delivery in relation to the incidence and the type of levator ani avulsion in primiparas.

Design:
Retrospective observational study.

Settimg:
Department of Obstetrics and Gynaecology, University Hospital of Ostrava.

Methodology:
In the study, the primiparas who were from 6 to 12 months after spontaneous vaginal delivery (group A, n = 52) or after childbirth with vacuum extraction (group B, n = 51) underwent translabial 3D ultrasound. The obstetric data had been obtained from the hospital database. Translabial 3D ultrasound examination were performed by two sonographists. The monitored parameter was the distance between urethra and fibres of musculus levator ani – levator urethra gap [6]. The distance longer than 25 mm was considered an avulsion injury [6, 22]. Other parameters assessed in relation to the avulsion were: women´s age, BMI, epidural analgesia, episiotomy performance, the length of the first and the second stages of labour, and fetal weight.

Results:
Musculus levator ani avulsion was diagnosed in 10 women – unilateral in 8 cases and bilateral in 2 cases. In group A, women after spontaneous birth, we noticed avulsion injury in 7.7% of cases, whereas in group B, women after vacuum extraction, we recorded avulsion injury in 11.8% of cases. Thus the use of vacuum extraction is not statistically significant risk factor for avulsion musculus levator ani. Statistically significant difference in comparison group A and B was recorded in BMI, the length of the second stages of labour and episiotomy performance.

Conclusion:
We did not prove a statistically significant connection between avulsion injury and delivery with the use of vacuum extraction in comparison to avulsion injury incidence in uncomplicated vaginal delivery group (tab. 1). Vacuum extraction does not appear as a risk factor for avulsion in contrast to forceps delivery.

Keywords:
3D ultrasound, avulsion injury, vacuum extraction, m. levator ani, pelvic floor

Zdroje

1. Allen, RE., et al. Pelvic floor damage and childbirth – a neurophysiological study. Brit J Obstet Gynaecol, 1990, 97(9), p. 770–779.

2. Bo, K., Fleten, C., Nystad, W. Effect of antenatal pelvic floor-muscle training on labor and birth. Obstet Gynecol, 2009, 113, p. 1279–1284.

3. Chaliha, C., et al. Anal function: Effect of pregnancy and delivery. Amer J Obstet Gynecol, 2001, 185(2), p. 427–432.

4. Chiaffarino, F., Chatenoud, L., Dindelli, M., et al. Repro-ductive factors, family history, occupation and risk of urogenital prolapse. Eur J Obstet Gynecol Reprod Biol, 1999, 82, p. 63–67.

5. De Lancy, JO., Morgan, DM., Fenner, DE., et al. Comparison of levator ani muscle defects and function in women with andwithout pelvic organ prolapsed. Obstet Gynecol, 2007, 109, p. 295–302.

6. Dietz, HP., Abbu, A., Shek KL. The levator – uretra gap measurement: a more objective means of determining levator avulsion. Ultrasound Obstet Gynecol, 2008, 32, p. 941–945.

7. Dietz, HP., Lanzarone, V. Levator trauma after vaginal delivery. Obstet Gynecol, 2005, 106, p. 707–712.

8. Dietz, HP., Lekskulchai, O. Older age at first delivery is associated with major levator trauma. Int Urogynecol J, 2006, 17 (S2), S148.

9. Dietz, HP., Shek, KL., Clarke, B. Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol, 2005, 25, p. 580–585.

10. Fitzpatrick, M., O’Brien, C., O’Connell, PR., et al. Patterns of abnormal pudendal associated with postpartum fecal incontinence. Am J Obstet Gynecol, 2003, 189, p. 730–735.

11. Guiney, HL. Post-partum observation of pelvic tissue damane. Am J Obstet Gynecol, 1943, 46, p. 457–466.

12. Handa, VL., Blomquist, JL., Knoepp, LR., et al. Pelvic floor disorders 5–10 years after vaginal or cesarean childbirth. Obstet Gynecol, 2011, 118, p. 777–784; Gynecology, 2008, 198(5).

13. Hartmann, K., et al. Outcomes of routine episiotomy: a systematic review. JAMA, 2005, 293(17), p. 2141–2148.

14. Kearney, R., et al. Obstetric factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol, 2006, 107(1), p. 144–149.

15. Kearney, R., Miller, JM., Delancey, J., et al. Obstetric factors associated wtih levator ani muscle injury after vaginal birth. Obstet Gynecol, 2006, 107, p. 144–149.

16. Krofta, L., Otcenasek, M., Kasikova, E., et al. Pubo-coccygeus-puborectalis trauma after forceps delivery: evaluation of the levator ani muscle with 3D/4D ultrasound. Int Urogynecol J, 2009, 20, p. 1175–1181.

17. Lavy, Y., Sand, KP., Kaniel, IC., et al. Can pelvic floor injury secondary to delivery be prevented? Int Urogynecol J, 2012, 23, p. 165–173.

18. Rahn, DD., et al. Biomechanical properties of the vaginal wall: effect of pregnancy, elastic fiber deficiency, and pelvic organ prolapse. Amer J Obstet Gynecol, 2008, 198(5).

19. Schiessl, B., Janni, W., Jundt, K., et al. Obstetrical parameters in fluencing the duration of the second stage of labor. Eur J Obstet Gynecol Reprod Biol, 2005, 118, p.17–20.

20. Schwertner-Tiepelmann, N., Thakar, R., Sultan, AH.,Tunn, R. Obstetric levator ani muscle injuries: current status. Ultrasound Obstet Gynecol, 2012, 39, p. 272–383.

21. Shek, KL., Dietz, HP. Intrapartum risk factors for levator trauma. Bjog-an Intern J Obstet Gynaecol, 2010, 117(12), p. 1485–1492.

22. Shek, KL., Dietz, HP., Clarke, B. Biometry of puborectal muscle and levator hiatus by 3D pelvic floor ultrasound. Neurol Urodyn, 2004, 23, p. 577–578.

23. Snopka, SJ., Swash, M., Henry, MM., et al. Risk factors in childbirth causing damage to the pelvic floor innervation. Int J Colorectal Dis, 1986,1, p. 20–24.

24. Svabik, K., Shek, KL., Dietz, HP. How much doesthe levator hiatus have to stretch during childbirth? BJOG 2009, 116, p. 1657–1662.

25. Toozs-Hobson, P., Balmforth, J., Cardozo, L., et al. The effect of mode of delivery on pelvic floor functional anatomy. Int Urogynecol J, 2008, 19, p. 407–416.

26. Viktrup, L., et al. The symptom of stress incontinence caused by pregnancy or delivery in primiparas. Obstet Gynecol, 1992, 79(6), p. 945–949.

27. Viktrup, L., Lose, G. The risk of stress incontinence 5 years after first delivery. Am J Obstet Gynecol, 2001, 185, p. 82–87.

28. Willis, A., Fardi, A., et al. Childbirth and incontinence: a prospective study on anal sphincter morphology and function before and early after vaginal delivery. Langenbecks Arch Surg, 2002, 387, p. 101.

29. Zong, W., et al. Repetitive mechanical stretch increases extracellular collagenase activity in vaginal fibroblasts. Female Pelvic Med Reconstr Surg, 2010, 16(5), p. 257–262.