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.

Background Perineal pain is common after childbirth. We studied the effect of genital tract trauma, labor care, and birth variables on the incidence of pain in a population of healthy women exposed to low rates of episiotomy and operative delivery. Methods A prospective study of genital trauma at birth and assessment of postpartum perineal pain and analgesic use was conducted in 565 midwifery patients. Perineal pain was assessed using the Present Pain Intensity (PPI) and Visual Analog Scale (VAS) components of the validated short form McGill pain scale. Multivariate logistic regression examined which patient characteristics or labor care measures were significant determinants of perineal pain and use of analgesic medicines. Results At hospital discharge, women with major trauma reported higher VAS pain scores (2.16 +/− 1.61 vs 1.48 +/− 1.40; P< 0.001) and were more likely to use analgesic medicines (76.3 vs 23.7%, P= 0.002) than women with mild or no trauma. By 3 months average VAS scores were low in each group and not significantly different. Perineal pain at the time of discharge was associated in univariate analysis with higher education level, ethnicity (non-Hispanic white), nulliparity, and longer length of active maternal pushing efforts. In a multivariate model only trauma group and length of active pushing predicted pain at hospital discharge. In women with minor or no trauma, only length of the active part of second stage labor had a positive relationship with pain. In women with major trauma, the length of active second stage labor had no independent effect on level of pain at discharge beyond its effect on the incidence of major trauma. Conclusions Women with spontaneous perineal trauma reported very low rates of postpartum perineal pain. Women with major trauma reported increased perineal pain compared with women who had no or minor trauma; however, by 3 months postpartum this difference was no longer present. In women with minor or no perineal trauma, a longer period of active pushing was associated with increased perineal pain.

BACKGROUND Perineal trauma after vaginal delivery can have significant long-term consequences. It is unknown if a larger infant head circumference (HC) or smaller maternal perineal anatomy are risk factors for perineal trauma after vaginal delivery. METHODS We conducted a prospective cohort study of low-risk nulliparous women. Data collected included maternal characteristics, antepartum POP-Q measurements of the perineal body and genital hiatus, labor characteristics, perineal trauma, and infant head circumference. Perineal trauma was defined as trauma that extended into the muscles of the perineum (second degree or deeper). Univariate and multivariate logistic models were created to calculate odd ratios (OR) and 95% confidence intervals (CI). RESULTS We observed 448 vaginal births. Multivariate analysis demonstrated a significant association between infant head circumference at birth and perineal trauma, OR 1.22 for each increase of 1cm in HC (95% CI 1.05-1.43). There was no association between perineal body or genital hiatus length and perineal trauma. CONCLUSIONS In nulliparous low-risk women a larger infant head circumference at birth increases the likelihood of perineal trauma, although the effect is modest. Antenatal perineal body and genital hiatus measurements do not predict perineal trauma. These results do not support alteration in mode of delivery or other obstetric practices.

OBJECTIVE To estimate promotion rates of physician faculty members in obstetrics and gynecology during the past 30 years METHODS Data were collected annually by the Association of American Medical Colleges from every school between 1980 and 2009 for first-time assistant and associate professors to determine whether and when they were promoted. Data for full-time physician faculty were aggregated by decade (1980–1989, 1990–1999, 2000–2009). Faculty were included if they remained in academia for 10 years after beginning in rank. Data were analyzed by constructing estimated promotion curves and extracting 6-year and 10-year promotion rates. RESULTS The 10-year promotion rates (adjusted for attrition) declined significantly for assistant professors from 35% in 1980–89 to 32% in 1990–99 to 26% in 2000–09 (p < 0.001); and for associate professors from 37% to 32% to 26% respectively (p < 0.005). These declines likely resulted from changes in faculty composition. The most recent 15 years saw a steady rise in the proportion of entry-level faculty who were women (now 2:1) and primarily on the non-tenure track. The rising number of faculty in general obstetrics and gynecology had lower promotion probabilities than those in the subspecialties (OR = 0.16, p < 0.001). Female faculty on the non-tenure track had lower promotion rates than males in the non-tenure track, males in the tenure track, and females in the tenure track (ORs ≤ 0.8, p < 0.01). CONCLUSION A decline in promotion rates during the past 30 years may be attributable to changes in faculty composition.