Skip to main content
Log in

Pubococcygeus–puborectalis trauma after forceps delivery: evaluation of the levator ani muscle with 3D/4D ultrasound

  • Original Article
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

Introduction and hypothesis

This study seeks to assess the effects of forceps-assisted delivery on the levator hiatus.

Methods

Seventy-six women were investigated 12 months after forceps-assisted delivery. Introital three-/four-dimensional ultrasound measured volumes at rest and during the Valsalva maneuver. Morphological parameters analyzed were angle gamma, hiatal area, pubovisceral angle, and continuity between the muscle and pelvic sidewall. Avulsion was diagnosed by loss of continuity.

Results

Forty-eight women had avulsion injuries, 23 had bilateral, and 25 had unilateral. Bilateral avulsion increased hiatal area during straining and at rest and was associated with changes in bladder neck position at rest. Unilateral avulsion injury was associated with a higher pubovisceral angle on the side of the avulsion.

Conclusion

Forceps-assisted vaginal delivery is associated with levator ani injury. Avulsion of the pubovisceral muscle seems more common after forceps delivery than after spontaneous vaginal delivery. Avulsion alters hiatal shape and area and influences the position and mobility of the anterior compartment.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Steensma AB, Dietz HP (2004) 3D pelvic floor ultrasound in the assessment of the levator ani muscle complex. Ultrasound Obstet Gynecol 24:258

    Article  Google Scholar 

  2. DeLancey JO, Kearney R, Chou Q, Speights S, Binno S (2003) The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 101:46–53

    Article  PubMed  Google Scholar 

  3. Lien KC, Mooney B, DeLancey JO, Ashton-Miller JA (2004) Levator ani muscle stretch inducted by simulated vaginal birth. Obstet Gynecol 103:31–40

    PubMed  Google Scholar 

  4. Mant J, Painter R, Vessey M (2006) Epidemiology of genital prolapse: observations from the Oxford Family Planning Association study. Br J Obstet Gynaecol 113:225–230

    Google Scholar 

  5. Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S (2001) Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPICONT study. Obstet Gynecol 98:1004–1010

    Article  PubMed  CAS  Google Scholar 

  6. Patel DA, Xu X, Thomason AD, Ransom SB, Ivy JS, DeLancey JO (2006) Childbirth and pelvic floor dysfunction: an epidemiologic approach to assessing prevention opportunities at delivery. Am J Obstet Gynecol 195:23–28

    Article  PubMed  Google Scholar 

  7. Hoyte L, Schierlitz L, Zou K, Flesh G, Fielding J (2001) Two- and 3-dimensional MRI comparison of levator ani structure, volume, and integrity in women with stress incontinence and prolapse. Am J Obstet Gynecol 185:11–19

    Article  PubMed  CAS  Google Scholar 

  8. Dietz HP, Lanzarone V (2005) Levator trauma after vaginal delivery Obstet Gynecol 106:707–712

    Google Scholar 

  9. Dietz HP (2007) Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol 29:329–334

    Article  PubMed  CAS  Google Scholar 

  10. Otcenasek M, Krofta L, Baca V et al (2007) Bilateral avulsion of the puborectal muscle: magnetic resonance imaging-based three-dimensional reconstruction and comparison with a model of a healthy nulliparous woman. Ultrasound Obstet Gynecol 29:692–696

    Article  PubMed  CAS  Google Scholar 

  11. DeLancey JO (2005) The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment. Am J Obstet Gynecol 192:1488–1495

    Article  PubMed  Google Scholar 

  12. Kearney R, Miller J, Ashton-Miller J, Delancey JO (2006) Obstetric factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol 107:144–149

    PubMed  Google Scholar 

  13. Dietz HP, Shek C, Clarke B (2005) Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol 25:580–585

    Article  PubMed  CAS  Google Scholar 

  14. Shrout PE, Fleiss JL (1979) Intraclass correlation: uses in assessing rater reliability. Psychological Bulletin 86:420–428

    Article  PubMed  CAS  Google Scholar 

  15. Hervé A (2007) The Bonferonni and Šidák corrections for multiple comparisons. In: Salkind Neil (ed) Encyclopedia of measurement and statistics. Sage, Thousand Oaks, CA

    Google Scholar 

  16. Braekken IH, Majida M, Ellstrom Engh M, Dietz HP, Umek W, Bo K (2008) Test- retest and intra-observer repeatability of two-, three- and four- dimensional perineal ultrasound of pelvic floor muscle anatomy and function. Int Urogynecol J 19:227–235

    Article  Google Scholar 

  17. Guaderrama N, Liu J, Nager C, Pretorius D, Sheean G, Kassab G et al (2006) Evidence for the innervation of pelvic floor muscles by the pudendal nerve. Obstet Gynecol 106(4):774–781

    Google Scholar 

  18. Dietz H, Simpson J (2007) Does delayed childbearing increase the risk of levator injury in labour? Aust NZ J Obstet Gynaecol 47:491–495

    Article  Google Scholar 

  19. Dietz HP, Wilson PD (1999) The influence of bladder volume on the position and mobility of the urethrovesical junction. Int Urogynecol J 10:3–6

    Article  CAS  Google Scholar 

  20. Tunn R, Schaer G, Peschers U, Bader W, Gauruder- Burmester A, Hanzal E et al (2005) Updated recommendations on ultrasonography in urogynecology. Int Urogynecol J 16:236–241

    Article  CAS  Google Scholar 

  21. Dietz HP (2004) Ultrasound imaging of the pelvic floor. Part I: two-dimensional aspects. Ultrasound Obstet Gynecol 23(1):80–92 [Review] [86 refs]

    Article  PubMed  CAS  Google Scholar 

  22. Kruger JA, Heap SW, Murphy BA, Dietz HP (2008) Pelvic floor function in nulliparous women imaged using three-dimensional ultrasound and magnetic resonance imaging. Obstet Gynecol 111:631–638

    PubMed  CAS  Google Scholar 

  23. Yang JM, Yang SH, Huang WC (2006) Biometry of the pubovisceral muscle and levator hiatus in nulliparous Chinese women. Ultrasound Obstet Gynecol 28:710–716

    Article  PubMed  Google Scholar 

  24. Krueger JA, Dietz HP (2007) Pelvic floor function in elite nulliparous athletes. Ultrasound Obstet Gynecol 30:81–85

    Article  Google Scholar 

  25. DeLancey JO, Hurd WW (1998) Size of the urogenital hiatus in the levator ani muscles in normal women and women with pelvic organ prolapse. Obstet Gynecol 91:364–368

    Article  PubMed  CAS  Google Scholar 

  26. DeLancey JO (2001) Anatomy. In: Cardovo L, Staskin D (eds) Textbook of female urology and urogynaecology. Isis Medical Media, London, UK, pp 112–124

    Google Scholar 

  27. Dietz HP, Steensma AB (2006) The prevalence of major abnormalities of the levator ani in urogynaecological patients. Br J Obstet Gynaecol 113:225–230

    CAS  Google Scholar 

  28. Lien KC, Morgan DM, DeLancey JO, Ashton-Miller JA (2005) Pudendal nerve stretch during vaginal birth: a 3D computer simulation. Am J Obstet Gynecol 192:1669–1676

    Article  PubMed  Google Scholar 

  29. Gainey HL (1955) Postpartum observation of pelvic tissue damage: further studies. Am J Obstet Gynecol 70:800–807

    PubMed  CAS  Google Scholar 

  30. Gainey HL (1943) Postpartum observation of pelvic tissue damage. Am J Obstet Gynecol 45:457–466

    Google Scholar 

  31. Ranney B (1990) Decreasing numbers of patients for vaginal hysterectomy and plasty. S D J Med 43:7–12

    PubMed  CAS  Google Scholar 

Download references

Acknowledgments

This study was supported by the Internal Grant Agency of the Ministry of Health of the Czech Republic, grant number NR 8353-3. We thank Associate Professor Karel Zvara MSc. Ph.D. for the important contribution to the data analysis and interpretation of results.

Conflicts of interest

None.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Ladislav Krofta.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Krofta, L., Otčenášek, M., Kašíková, E. et al. Pubococcygeus–puborectalis trauma after forceps delivery: evaluation of the levator ani muscle with 3D/4D ultrasound. Int Urogynecol J 20, 1175–1181 (2009). https://doi.org/10.1007/s00192-009-0837-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00192-009-0837-6

Keywords

Navigation