Timing of caesarean section and its impact on levator ani musle avulsion at the first subsequent vaginal birth – a pilot study
Authors:
L. Paymová 1; K. Švabík 2; V. Kališ 1; K. M. Ismail 3; Z. Rušavý 1
Authors‘ workplace:
Gynekologicko-porodnická klinika LF UK a FN Plzeň
1; Gynekologicko-porodnická klinika 1. LF UK a VFN v Praze
2; Biomedicínské centrum, LF UK Plzeň
3
Published in:
Ceska Gynekol 2022; 87(3): 173-178
Category:
Original Article
doi:
https://doi.org/10.48095/cccg2022173
Overview
Objective: The aim of this multicentric observational study was to explore the impact of the timing of cesarean section (SC) on levator (MLA – levator ani musle) avulsion at the first subsequent vaginal birth. Methods: All women after term vaginal birth following a cesarean section (VBAC) for their second delivery at the Departments of Gynecology and Obstetrics, Faculty of Medicine, Charles University and University Hospital in Pilsen and the 1st Faculty of Medicine, Charles University and General Hospital in Prague, between 2012 and 2016 were identified. Hospital database and surgical notes were used to collect basic characteristics of the patients including the indication and course of their previous delivery. These women were divided into two groups according to indication of prior SC in the previous delivery to women with elective SC and acute SC. All participants were invited for a 4D pelvic floor ultrasound to assess levator trauma. Levator avulsion and the levator hiatus area were assessed off-line from the stored pelvic floor volumes. Data were statistically assessed. 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 141 women for statistical analyses. These were further divided into 80 women after acute SC and 61 women after elective SC. The levator avulsion rate was higher in the elective SC subgroup, but the difference was not significant (26.3 vs. 41.0%, P = 0.0645). No statistical differences in urogenital hiatus enlargement and ballooning were observed. Conclusion: VBAC is associated with a significantly higher rate of levator ani avulsion compared to the first vaginal birth in nulliparous women. However, it seems that risk of levator ani avulsion doesn’t depend on the timing of SC in previous labor. More studies are needed to confirm the results of this pilot study.
Keywords:
4D transperineal ultrasound – avulsion injury – levator ani muscle – vaginal birth after cesarean section – pelvic fl oor
Sources
1. Gardner K, Henry A, Thou S et al. Improving VBAC rates: the combined impact of two management strategies. Aust N Z J Obstet Gynaecol 2014; 54(4): 327–332. doi: 10.1111/ ajo.12 229.
2. Guise JM, Denman MA, Emeis C et al. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol 2010; 115(6): 1267–1278. doi: 10.1097/ AOG. 0b013e3181df925f.
3. Declercq E, Cabral H, Ecker J. The plateauing of cesarean rates in industrialized countries. Am J Obstet Gynecol 2017; 216(3): 322–323. doi: 10.1016/ j.ajog.2016.11.1038.
4. Zhang J, Troendle J, Reddy UM et al. Contemporary cesarean delivery practice in the United States. Am J Obstet Gynecol 2010; 203(4): 326.e1–326.e10. doi: 10.1016/ j.ajog.2010.06. 058.
5. Dietz HP, Campbell S. Toward normal birth – but at what cost? Am J Obstet Gynecol 2016; 215(4): 439–444. doi: 10.1016/ j. ajog.2016.04.021.
6. Hehir M, Mackie A, Robson MS. Simplified and standardized intrapartum management can yield high rates of successful VBAC in spontaneous labor. J Matern Fetal Neonatal Med 2017; 30(12): 1504–1508. doi: 10.1080/ 14767058.2016.1220522.
7. Dietz HP, Shek KL, Chantarasorn V et al. Do women notice the effect of childbirth‐related pelvic floor trauma? Aust N Z J Obstet Gynaecol 2012; 52(3): 277–281. doi: 10.1111/ j.1479-828X.2012.01432.x.
8. Manzini C, Friedman T, Turel F et al. Vaginal laxity: which measure of levator ani distensibility is most predictive? Ultrasound Obstet Gynecol 2020; 55(5): 683–687. doi: 10.1002/ uog.21 873.
9. Dietz HP, Franco AV, Shek KL et al. Avulsion injury and levator hiatal ballooning: two independent risk factors for prolapse? An observational study. Acta Obstet Gynecol Scand 2012; 91(2): 211–214. doi: 10.1111/ j.1600- 0412.2011.01315.x.
10. Dietz HP. Quantifi cation of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol 2007; 29(3): 329–334. doi: 10.1002/ uog.3951.
11. Thibault-Gagnon S, Yusuf S, Langer S et al. Do women notice the impact of childbirth-related levator trauma on pelvic floor and sexual function? Results of an observational ultrasound study. Int Urogynecol J 2014; 25(10): 1389–1398. doi: 10.1007/ s00192-014-23 31-z.
12. Rusavy Z, Paymová L, Kozerovsky M et al. Levator ani avulsion: a systematic evidence review (LASER). BJOG 2022; 129(4): 517–528. doi: 10.1111/ 1471-0528.16837.
13. Paymova L, Svabik K, Neumann A et al. Vaginal birth after cesarean section and levator ani avulsion: a case-control study. Ultrasound Obstet Gynecol 2021; 58(2): 303–308. doi: 10.1002/ uog.23629.
14. Rusavy Z, Francova E, Paymova L et al. Timing of cesarean and its impact on labor duration and genital tract trauma at the fi rst subsequent vaginal birth: a retrospective cohort study. BMC Pregnancy Childbirth 2019; 19(1): 207. doi: 10.1186/ s12884-019-2359-7.
15. Dietz H, Abbu A, Shek KL. The levator-urethra gap measurement: a more objective means of determining levator avulsion? Ultrasound Obstet Gynecol 2008; 32(7): 941–945. doi: 10.1002/ uog.6268.
16. Dietz HP, Bernardo MJ, Kirby A et al. Minimal criteria for the diagnosis of avulsion of the pubo rectalis muscle by tomographic ultrasound. Int Urogynecol J 2011; 22(6): 699–704. doi: 10.1007/ s00192-010-1329-4.
17. Dietz HP, Shek C, Clarke B. Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol 2005; 25(6): 580–585. doi: 10.1002/ uog.1899.
18. Handa VL, Pierce CB, Muŋoz A et al. Longitudinal changes in overactive bladder and stress incontinence among parous women. Neurourol Urodyn 2015; 34(4): 356–361. doi: 10.1002/ nau.22583.
19. Nandikanti L, Sammarco AG, Kobernik EK et al. Levator ani defect severity and its association with enlarged hiatus size, levator bowl depth, and prolapse size. Am J Obstet Gynecol 2018; 218(5): 537–539. doi: 10.1016/ j.ajog.2018.02.005.
20. Friedman T, Eslick GD, Dietz HD. Delivery mode and the risk of levator muscle avulsion: a meta-analysis. Int Urogynecol J 2019; 30(6): 901–907. doi: 10.1007/ s00192-018-38 27.8.
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Paediatric gynaecology Gynaecology and obstetrics Reproduction medicineArticle was published in
Czech Gynaecology
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