Childbirth and the Female

Pelvic Floor

Christopher Maher
Wesley Urogynaecology

Brisbane Australia

www.urogynaecology.com.au
                                            

  
 PF muscle stretch during labour

• During 2nd stage the

PF muscles stretch
x 2-3 of their length
• Maximal stretch
tolerated by
nonpregnant animal
muscle tissue = 1.5
 PF muscle stretch during labour

• Simulated delivery
31y-o mother at 40w
• Largest strain 259%
(=3.6 stretch ratio)

• Blue area near pubic

bone – location of
muscle defects
observed on MRI.
Pudendal Nerve Latency Studies

PNTML  42% post vag delivery

Changes recovered 2/12
Unchanged after elective CS
Snooks 1990 Br J Surg

Concentric needle EMG duration

motor unit potential  vaginal ,
unchanged CS
80% reinnervation
Allen Br J Obstet Gyn
 Muscular injuries postpartum

• 35% primaparous & 44%

multiparous anal sphincter
damage 3/12
 Muscular injuries postpartum

• 35% primaparous & 44%

multiparous anal sphincter
damage 3/12
 Levator Ani Muscles

• MRI evaluation no
defects levator ani
muscle nulliparous as
compared to 20%
primaparous women

Delancey Obstet Gyn 2003

MRI defects in parous womnen
Unilateral Bilateral
 3D US defects in parous womnen

A – Normal
B – Unilateral Avulsion
C – Bilateral Avulsion

Dietz BJOG 2008

Childbirth & Fecal Incontinence

• 259 consecutive women delivered single unit

• 31 elective CS no FI
• Primaparous delivered vaginally 13% FI
Abromowitz Dis Colon Rectum 2000

• 549 prospective fecal urgency vag 7.3% vs

CS 3.1% Chaliha 99 Obstet Gyn
Childbirth & Fecal Incontinence

• Retospective review 30 yrs post delivery

• FI equal vaginal delivery, elective or emergency CS

Nygaard I Obstet Gyn

1997
Int Urogynecol J 2009

• Prospective cohort 246 primiparous women

• Singleton, cephalic VD in 1995
• Anorectal symptoms questionnaires at 0, 9
months, 5 and 10 years
• 3rd/4th deg tear 35/246 (14%)
Int Urogynecol J 2009
Int Urogynecol J 2009
Childbirth and Urinary Incontinence

• Large population based study

• Norwegian EPINCORT study
• Vaginal delivery 2.2x likely UI those elective CS
• Estimated elective CS UI 10 to 5%
Rortveit G, Obstet Gynecol. 2001

• 1596 Term breech trial CS vaginal delivery

• UI 3/12: 4.3% elective CS 7.3% vaginal group
RR 0.62 (95% CI 0.41-0.93)
Hannah M JAMA 2002
Childbirth and Urinary Incontinence

• Long-term population studies women 50-60

age group had the same rate UI regardless of
mode of delivery
Rortveit G, Obstet Gynecol.
2001
AJOG 2005

• The world’s largest annual gathering of

identical twins held in Twinsburg, Ohio
• 271 identical twin pairs (n=542)
• A 67-item survey of incontinence and pelvic
floor symptoms
AJOG 2005
Int Urogynecol J 2008

• Prospective controlled cohort study

• 220 elective C/S, 215 VD
• LUT symptoms questionnaire 3 & 9 months
postpartum
 Childbirth and Pelvic Organ
Prolapse

• Parity risk POP

• Parity  surgery POP
Childbirth and Pelvic Organ
Prolapse
Women’s Health Initiative:
• single childbirth associated
with raised odds of:
– Uterine prolapse (odds ratio
2.1; 95% CI 1.7–2.7)
– Cystocoele (2.2; 1.8–2.7)
– Rectocele (1.9; 1.7–2.2)
• Every additional delivery
increased the risk of
worsening prolapse by
10–20% (Hendrix, Am J Obstet
Gynecol 2002).
 Childbirth and Pelvic Organ
Prolapse
100

80

Stage
60
0/1
% 2
40
3+

20

0
0 1 to 3 >3

# vaginal deliveries
Swift, 2001
AJOG 2009

• 1.4 million Swedish women

• Hospital & Medical Birth Registries linked
• Correlation sought C/S and POP
• C/S ↓ risk of POP OR 0.18 (CI 0.16-0.20)
Pregnancy or Delivery Culprit?

• Prolapse > nulliparous preg

than nulliprous non preg
O’boyle 2002 AmJ
OG

• Emergency CS same POP

vaginal delivery
McLennan BJOG 2000
How often do these problems occur?
Incontinence after birth

No Caesareans Vaginal Instrumental

births ection delivery delivery
Stress 11% 33% 41% 44%

Urge 4% 10% 19% 20%

Faecal 2% 4% 5% 11%

MacLennan and collegues, BJOG 2000

Increased risks for pelvic floor symptoms

Caesarean section 2.5

Spontaneous vaginal delivery 3.4
Instrumental vaginal delivery 4.3

• Compared with no births

MacLennan and collegues, BJOG 2000

 Predisposing factors

Childbirth

Tissue Damage Nerve Injury

Promoting
Ageing Factors

Pelvic Floor Disorder

PREDISPOSE INCITE PROMOTE
Gender Childbirth Constipation
Race Radiation Occupation
Anatomic Nerve damage Smoking
Neurologic Surgery COPD
Collagen Obesity
Infection
DECOMPENSATE Medications
Ageing
Dementia Pelvic Floor Disorders
Decreased mobility
 Prevalence of pelvic organ prolapse
& pelvic floor symptoms in women in
the community: A longitudinal study

Dr Kaven Baessler, Dr Sheila O’Neill, Dr

Christopher Maher
Betty Byrne Henderson Women’s Health Research
Centre
Royal Brisbane & Women’s Hospital
 Subjects

• LAW (Longitudinal Assessment of Ageing in

Women) Study
– a multidisciplinary evaluation of ageing in women
– 8 interlinked projects
• Approx 500 women randomly recruited from the
North Brisbane electoral roll
• Equally distributed across 4 age groups –
– 40-49, 50-59, 60-69, 70-79 years
 Results
Prevalence Year 1

60%

51%
51%
50%
44% Stress incontinence
48%

40% Urge incontinence

40%
32%
31%
30%
24%
22% 24% Prolapse surgery
27%

20%
20%

10%

0%
40-49 50-59 60-69 70-79
 Risk factors Results
bladder dysfunction
LAW study
• Stress incontinence associated with BMI and HRT
– BMI > 25: x 1.6
– BMI > 30: x 1.8
– Systemic HRT >12 months: x 1.5
– No association with age or mode of delivery
• Urge incontinence associated with age and HRT
– Age > 70 years: x 2.1
– Systemic HRT >12 months: x 1.6
– No association with BMI or mode of delivery
Prolapse stages & mode of delivery

96% 94%
91%
86%
82% 91%
75%

67%

43%
3

39% 2
1
23%
18% 0
4% 6% 23%
2%
9% 14% 18%
9%
10%
0.2%
 Results
 Prolapse stage 2 or more was significantly
associated with age, mode of delivery and HRT
–Age > 60 years: x 2.2
–Age > 70 years: x 2.3
–Vag. Delivery (compared to NP): x 16
none of the women with caesarean section
developed prolapse (n=22)
– Systemic HRT >12 months: x 1.6
 Childbirth & Pelvic Floor

• Pelvic floor dysfunction multifactorial

• Vaginal delivery > elective CS pelvic floor?
• Impact mode delivery on SUI or FI not
defined
• Likely elective CS protect against POP
• Pelvic floor dysfunction multifactorial
IUGA
2012