Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion

Youssef, A.; Salsi, G.; Cataneo, I.; Pacella, G.; Azzarone, C.; Paganotto, M.; Krsmanovic, J.; Montaguti, Elisa; Cariello, L.; Bellussi, Federica; Rizzo, Nicola; Pilu, Gianluigi

doi:10.1002/uog.19085

Cited by 57 publications

(47 citation statements)

References 37 publications

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“…Pregnancy and delivery are associated with an increased risk of pelvic floor dysfunction [1][2][3] . With the introduction of imaging techniques, especially transperineal ultrasound (TPU), our understanding of the relationship between vaginal delivery and pelvic floor dysfunction has improved [4][5][6][7][8] . Over the past few years, much effort has been spent diagnosing and identifying risk factors for pelvic floor muscle injury, which seems to be the connection between vaginal delivery and the development of prolapse and pelvic floor dysfunction [9][10][11][12][13][14][15][16][17][18] .…”

Section: Introductionmentioning

confidence: 99%

Levator ani muscle coactivation at term is associated with longer second stage of labor in nulliparous women

Youssef

Montaguti

Dodaro

et al. 2019

Ultrasound in Obstet & Gyne

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Objective To assess the effect of levator ani muscle (LAM) coactivation at term on outcome of labor in nulliparous women. Methods This was a prospective study of 284 low‐risk nulliparous women with a singleton pregnancy at term recruited before the onset of labor. The anteroposterior diameter of the levator hiatus was measured in each woman on transperineal ultrasound at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver before and after visual feedback. LAM coactivation was defined as a reduction in the anteroposterior diameter of the levator hiatus on maximum Valsalva maneuver in comparison with that at rest. The association of pelvic hiatal diameter values and LAM coactivation with mode of delivery and duration of labor was assessed. Results No significant difference was found between women who underwent Cesarean delivery and those who had a vaginal delivery with regard to the anteroposterior diameter of the levator hiatus at rest, on pelvic floor muscle contraction and on Valsalva maneuver. Longer second stage of labor was associated with shorter anteroposterior diameter of the levator hiatus on all assessments, but in particular at rest and on Valsalva both before and after visual feedback. LAM coactivation was found in 89 (31.3%) and 75 (26.4%) women before and after visual feedback, respectively. Post visual feedback, women with LAM coactivation had a significantly longer second stage of labor than did those without LAM coactivation (83 ± 63 vs 63 ± 42 min; P = 0.006). On Cox regression analysis, LAM coactivation post visual feedback was an independent predictor of longer second stage of labor (adjusted hazard ratio, 1.499 (95% CI, 1.076–2.087); P = 0.017). Conclusion LAM coactivation in nulliparous women at term is associated with a longer second stage of labor. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

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Section: Introductionmentioning

confidence: 99%

Levator ani muscle coactivation at term is associated with longer second stage of labor in nulliparous women

Youssef

Montaguti

Dodaro

et al. 2019

Ultrasound in Obstet & Gyne

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“…The definition of overdistention used in our study has previously been employed in a postpartum analysis that determined that overdistention occurred in 15.7% of eutocic births. 20 If these data are compared with those previously obtained for avulsion, with an adjusted OR of 2.14 (95% CI: 0.95, 4.85) (P = .068) between forceps delivery and vacuum delivery, 21 we observe a greater difference for overdistention than for avulsion between the assisted vaginal delivery methods. The diagnostic criteria for overdistention of the levator hiatus after delivery are not as standardized as those for avulsion.…”

Section: Discussionmentioning

confidence: 67%

“…The LAM area on Valsalva was larger after forceps delivery than after vacuum delivery. The definition of overdistention used in our study has previously been employed in a postpartum analysis that determined that overdistention occurred in 15.7% of eutocic births 20 …”

Section: Discussionmentioning

confidence: 99%

Prevalence of levator hiatal overdistension after vacuum and forceps deliveries

Bueno

González-Díaz

Martínez

et al. 2020

Neurourology and Urodynamics

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Introduction: Levator ani avulsion rates after assisted vaginal delivery have been reported in the literature. However, there are no definitive data regarding the association between overdistention and assisted vaginal delivery. Therefore, our aim is to report overdistention rates after assisted vaginal delivery with a postpartum ultrasound examination. Materials and Methods:This multicenter study involved a retrospective analysis of data from primiparous women (n = 602) who had previously been recruited at three tertiary hospitals between January 2015 and January 2017. Overdistention was assessed at 6 months postpartum using three-/four-dimensional transperineal ultrasound. Patients with levator ani muscle avulsion were excluded. Overdistention was defined as a levator hiatal area ≥ 25 cm 2 on Valsalva.Results: Of the 602 primiparous patients, 250 patients who satisfied the inclusion criteria (139 patients who underwent forceps delivery and 111 patients who underwent vacuum delivery) were evaluated. Overdistention occurred in 20% (50 of 250) of these patients. Overdistention was observed for 1% (1/111) of vacuum deliveries and 35.3% (49 of 139) of forceps deliveries. We found an increased risk of overdistention following forceps delivery compared to vacuum delivery, with a crude odds ratio (OR) of 59.9 (95% confidence interval [CI]: 8.1, 442.2) and an adjusted OR (adjusted for maternal age, second-stage duration, and head circumference) of 17.6 (95% CI: 2.3, 136.7).Conclusions: Postpartum overdistention occurred for 20% of assisted vaginal deliveries, with an increased risk of overdistention following forceps delivery compared to vacuum delivery. K E Y W O R D S3D transperineal ultrasound, forceps delivery, levator ani muscle, overdistention, vacuum delivery

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“…Instrumentation (MVD or KFD) was used during uterine contraction in conjunction with active maternal pushing. Two to three tractions per contraction were applied, without use of the Kristeller maneuver, to avoid further confounding factors. Restrictive episiotomy and protection of the maternal perineum was performed in all cases at the time of fetal head bulging.…”

Section: Methodsmentioning

confidence: 99%

Malmström vacuum or Kielland forceps: which causes more damage to pelvic floor?

García‐Mejido

Martín‐Martinez

González-Díaz

et al. 2020

Ultrasound in Obstet & Gyne

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Objective To determine whether differences exist in the rate of levator ani muscle (LAM) avulsion between women who had undergone either Malmström vacuum delivery (MVD) or Kielland forceps delivery (KFD), allowing for potential confounding factors. Methods This was a prospective observational study of nulliparous women undergoing instrumental delivery using Malmström vacuum extractor or Kielland forceps, at two hospital centers in Spain. Fetal head position (anterior, posterior or transverse) and fetal head station (low or mid) were assessed by ultrasound and digital examination, respectively. Avulsion was defined on tomographic ultrasound imaging as an abnormal insertion of the LAM in the three central slices from the plane of minimal hiatal dimensions. Results In total, 414 patients were included in the study (212 MVD and 202 KFD). We observed a higher rate of LAM avulsion in the KFD group (KFD 49.5% vs MVD 32.5%; P = 0.001). When the results were evaluated according to fetal head position and station, we observed no differences in LAM avulsion. The crude odds ratio (OR) for the difference in avulsion between women in the KFD and MVD groups was 2.03 (95% CI, 1.36–3.03). However, when adjusted for duration of second stage of labor, fetal head circumference and fetal head station, the OR was no longer statistically significant (OR, 2.14 (95% CI, 0.95–4.85); P = 0.068). Conclusion When potential confounding factors are taken into account, the rate of LAM avulsion does not differ between women according to whether they have undergone KFD or MVD. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

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Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion

Cited by 57 publications

References 37 publications

Levator ani muscle coactivation at term is associated with longer second stage of labor in nulliparous women

Levator ani muscle coactivation at term is associated with longer second stage of labor in nulliparous women

Prevalence of levator hiatal overdistension after vacuum and forceps deliveries

Malmström vacuum or Kielland forceps: which causes more damage to pelvic floor?

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