Levator ani defect severity and its association with enlarged hiatus size, levator bowl depth, and prolapse size

Nandikanti, Lahari; Sammarco, Anne G.; Kobernik, Emily K.; DeLancey, John O.L.

doi:10.1016/j.ajog.2018.02.005

Cited by 20 publications

(12 citation statements)

References 6 publications

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“…1 Hence, levator ani muscle injury is related to the appearance of pelvic organ prolapse 1-3 (affecting mainly the anterior and middle compartments 4,5 ) as well as to fecal incontinence during the postpartum period [6][7][8] and in elderly women. 11 The main risk factor for the appearance of these levator ani muscle injuries is vaginal delivery, 12 which is associated with an increase in the levator muscle hiatus, 13,14 especially in cases of levator ani muscle avulsion. 11 The main risk factor for the appearance of these levator ani muscle injuries is vaginal delivery, 12 which is associated with an increase in the levator muscle hiatus, 13,14 especially in cases of levator ani muscle avulsion.…”

Section: Introductionmentioning

confidence: 99%

“…9 Levator ani muscle avulsion, defined as the disconnection of levator muscle fibers from their insertion on the inferior pubic ramus, 10 is present in 10%-35% of women after a vaginal delivery. 11 The main risk factor for the appearance of these levator ani muscle injuries is vaginal delivery, 12 which is associated with an increase in the levator muscle hiatus, 13,14 especially in cases of levator ani muscle avulsion. 15 In addition, specific muscle parameters are altered, such as passive properties, strength, contraction speed and resistance.…”

Section: Introductionmentioning

confidence: 99%

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A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation

García‐Mejido

Fernández‐Palacín

Barby

et al. 2019

Acta Obstet Gynecol Scand

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Abbreviations: CI, confidence interval; LAM, levator ani muscle; OR, odds ratio. AbstractIntroduction: Forceps delivery is associated with a high rate of levator ani muscle (LAM) trauma (avulsion) at 35%-65% whereas data on avulsion rates after vacuum delivery vary greatly. Nevertheless, a common characteristic of all previous studies carried out to evaluate the association between instrumental deliveries (forceps and vacuum) and LAM avulsion, is the fact that characteristics of the instrumentation have not been described or evaluated. The objective of this study is to compare the rate of LAM avulsion between forceps and vacuum deliveries according to the characteristics of the instrumentation. Material and methods: Prospective, observational study, including 263 nulliparous women, who underwent an instrumental delivery with either Malmström vacuum or Kielland forceps. The characteristics of the instrumentation, position (anterior position and other position) and height of the fetal head at the moment of instrumentation (low instrumentation [vertex at +2 station] and mid-instrumentation [head isinvolved but leading part above +2 station]) were assessed. Evaluation of LAM avulsion was performed at 6 months postpartum by three-/four-dimensional transperineal ultrasound. Using the multi-view mode, a complete avulsion was diagnosed when the abnormal muscle insertion was identified in all three central slices, that is, in the plane of minimal hiatal dimensions and the 2.5-mm and 5.0-mm slices cranial to this one. To detect a 30% or 15% difference in the LAM injury rate, with 80% power and 5% α-error, we needed, respectively 42 and 99 women per study group.Results: In all, 263 nulliparous individuals have been evaluated (162 vacuum deliveries, 101 forceps deliveries). Instrumentation in an occipito-anterior position was more frequent in vacuum deliveries (75.3% vs 56.4%, P = .002), whereas other positions were more frequent in the forceps deliveries group (24.7% vs 43.6%). No statistically significant differences were noted regarding the height of the fetal head at the moment of instrumentation. No statistically significant differences were found in the presence of LAM avulsion (41.4% vs 38.6%) between vacuum and forceps deliveries.The univariate analysis of the crude odds ratio was 1.17, 95% CI 0.67-1.98, P = .70 for

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation

García‐Mejido

Fernández‐Palacín

Barby

et al. 2019

Acta Obstet Gynecol Scand

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“…Urogenital hiatus enlargement probably occurs later in life 26 . Furthermore, only a small proportion of ballooning of the levator hiatus can be explained by LAM injury at the time of childbirth 27 .…”

Section: Discussionmentioning

confidence: 99%

Vaginal birth after Cesarean section and levator ani avulsion: a case–control study

Paymova

Švabík

Neumann

et al. 2021

Ultrasound in Obstet & Gyne

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Objective The aim of this study was to explore the risk of levator ani muscle (LAM) avulsion and enlargement of the levator hiatus following vaginal birth after Cesarean section (VBAC) in comparison with vaginal delivery in primiparous women. Methods In this two‐center observational case–control study, we identified all women who had a term VBAC for their second delivery at the Departments of Obstetrics and Gynecology at the Faculty of Medicine in Pilsen and the 1st Faculty of Medicine in Prague, Charles University, Czech Republic, between 2012 and 2016. Women with a repeat VBAC, preterm birth or stillbirth were excluded from the study. As a control group, we enrolled a cohort of primiparous women who delivered vaginally during the study period. To increase our control sample, we also invited all primiparous women who delivered vaginally in both participating units between May and June 2019 to participate. All participants were invited for a four‐dimensional pelvic floor ultrasound scan to assess LAM trauma. LAM avulsion and the area of the levator hiatus were assessed offline from the stored pelvic floor volumes obtained at rest, during maximum contraction and during Valsalva maneuver. The laterality of the avulsion was also noted. The cohorts were then compared using the χ2 test and Wilcoxon's two‐sample test according to the normality of the distribution. P < 0.05 was considered statistically significant. Multivariate regression analysis, controlling for age and body mass index (BMI), was also performed. Results A total of 356 women had a VBAC for their second delivery during the study period. Of these, 152 (42.7%) attended the ultrasound examination and full data were available for statistical analysis for 141 women. The control group comprised 113 primiparous women. A significant difference was observed between the VBAC group and the control group in age (32.7 vs 30.1 years; P < 0.05), BMI (28.4 vs 27.4 kg/m2; P < 0.05) and duration of the first and second stages of labor (293.1 vs 345.9 min; P < 0.05 and 27.6 vs 35.3 min; P < 0.05, respectively) at the time of the index birth. The LAM avulsion rate was significantly higher in the VBAC compared with the control group (32.6% vs 18.6%; P = 0.01). The difference between the groups was observed predominantly in the rate of unilateral avulsion and remained significant after controlling for age and BMI (adjusted odds ratio 2.061 (95% CI, 1.103–3.852)). There was no statistically significant difference in the area of the levator hiatus at rest (12.0 vs 12.6 cm2; P = 0.28) or on maximum Valsalva maneuver (18.6 vs 18.7 cm2; P = 0.55) between the VBAC and control groups. The incidence of levator hiatal ballooning was comparable between the groups (17.7% and 18.6%; P = 0.86). Conclusions VBAC is associated with a significantly higher rate of LAM avulsion than is vaginal birth in nulliparous women. The difference was significant even after controlling for age and BMI. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

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“…Instrumental delivery results in an increase in neonatal morbidity (subdural or cerebral hemorrhage, seizures and need for mechanical ventilation) and maternal morbidity (hemorrhage, perineal injuries). However, these are not the only injuries that occur during labor; there are other types of muscle trauma, such as levator ani muscle (LAM) avulsion, which can influence the future occurrence of pelvic floor dysfunction.…”

Section: Introductionmentioning

confidence: 99%

“…LAM injury caused during childbirth can lead to an increase in size of the levator hiatus and a decrease in muscle strength, contraction speed and resistance, and is associated with lower strain of the puborectalis muscle. In addition, LAM injury is associated with the development of pelvic organ prolapse, urinary incontinence and fecal incontinence during the postpartum period.…”

Section: Introductionmentioning

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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Levator ani defect severity and its association with enlarged hiatus size, levator bowl depth, and prolapse size

Cited by 20 publications

References 6 publications

A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation

A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation

Vaginal birth after Cesarean section and levator ani avulsion: a case–control study

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

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