Operative Vaginal Delivery and Pelvic Floor Trauma. Anna Padoa, MD Urogynecology Service Dept of Ob & Gyn Assaf Harofe Medical Center

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1 + Operative Vaginal Delivery and Pelvic Floor Trauma Anna Padoa, MD Urogynecology Service Dept of Ob & Gyn Assaf Harofe Medical Center

2 + Vaginal birth and the pelvic floor Mechanisms of injury Damage to muscles Denervation Damage to endopelvic fascia Handa et al, Obstet Gynecol.1996 Sep;88(3):470-8

3 + Vaginal birth and the pelvic floor Muscle injury Levator ani muscle: 1. pubovisceral complex pubovaginal, puboperineal, puboanal portions 2. puborectalis and iliococcygeus muscles Ashton-Miller JA, Delancey JO. Annu Rev Biomed Eng. 2009;11:163-76

4 + Vaginal birth and the pelvic floor Muscle injury The load acting normal to the pelvic floor is approximately 37 N in quiet standing and 19 N in the supine posture During a maximum cough: peak load of 129 N Straining at stool: 92 N expulsive forces on the fetal head: 16 N at rest, 54 N during a uterine contraction, and 120 N during a volitional push Vacuum device: additional traction force of up to 113 N Forceps: additional traction force can reach 200 N Ashton-Miller JA, Delancey JO. Annu Rev Biomed Eng. 2009;11:163-76

5 + Vaginal birth and the pelvic floor Muscle injury Second stage of labor Overstretching: parts of the muscle that are stretched the most are seen to be injured Pubovisceral (pubococcygeal): stretch ratio of Iliococcygeus, pubococcygeus, puborectalis: stretch ratios of 2.73, 2.50, and These values exceed the maximum stretch ratio of 1.5 tolerated by striated muscle in nonpregnant animal preparations Ashton-Miller JA, Delancey JO. Annu Rev Biomed Eng. 2009;11:163-76

6 + Vaginal birth and the pelvic floor Muscle injury Women with levator defects may be around twice as likely to develop pelvic organ prolapse later in life. Levator Avulsion in POP patients (MRI): 55% vs 16% in controls DeLancey JO et al. Obstet Gynecol. 2007Feb;109(2 Pt 1): Dietz HP, Simpson JM. BJOG 2008;115: Rates of Levator Ani damage following vaginal delivery (Trans-perineal US): 18.8%- 38.5% after SVD, 45%-71% after OVD Albrich SB et al. BJOG Jan;119(1):51-60 Dietz HP, Lanzarone V. Obstet Gynecol Oct;106(4): Valsky DV et al. Am J Obstet Gynecol Jul;201(1):91.e1-7 Chan SS et al.ultrasound Obstet Gynecol Jun;39(6):704-9

7 + Vaginal birth and the pelvic floor Muscle injury When a passive muscle is stretched, its force depends on two factors: the strain rate the product of the strain times the strain rate. An order-of-magnitude increase in the strain rate can increase the peak force by 25%. Hence, a physician performing an instrumented delivery is probably wise to keep the rate of pelvic muscle stretch as low as possible by delivering the fetal head as slowly as is reasonable Ashton-Miller JA, Delancey JO. Annu Rev Biomed Eng. 2009;11:163-76

8 + Vaginal birth and the pelvic floor Nerve injury PUDENDAL NERVE STRETCH DURING VAGINAL BIRTH: the inferior rectal branch exhibited the maximum strain: 35% which varied by 15% from least perineal descent to most perineal descent branches innervating the posterior labia and urethral sphincter reached values of 15% and 13% nerves innervating the anal sphincter are stretched beyond the 15% strain threshold known to cause permanent damage in nonpregnant appendicular nerve Lien KC et al. Am J Obstet Gynecol. 2005May;192(5):

9 + Vaginal birth and the pelvic floor Endopelvic fascia Isolated breaks in the endopelvic fascia: implicated in the genesis of cystoceles, vaginal support defects and SUI. After an acute injury new collagen is formed, which is never as strong as the original connective tissue. Following levator ani avulsion, loss of support exposes the endopelvic fascia to gradual stretching and weakening In a computerized model simulating vaginal delivery, Lepage et al found the uterosacral ligaments to be submitted to traction: for a medium-sized fetal head, uterosacral ligaments undergo a deformation near 30 % Lepage J et al.int Urogynecol J Apr;26(4):

10 + Operative Vaginal Delivery and the Pelvic Floor Possible damage to pelvic floor function caused by operative vaginal delivery: 1. Anal sphincter Disruption/ OASIS 2. Urinary Incontinence 3. Pelvic Organ Prolapse

11 + Operative Vaginal Delivery and anal incontinence Author & date N FU results p Groutz, primips 3 mo AI 3.8% after SVD, 25% after VE Meyer, forceps 82 SVD Peschers, VE 50 SVD Casey, primips Mean 219 days Liebling, OVD 209 CS 2 st Handa, SVD/OVD/CS Macleod, VE 904 forceps 10 mo AI 4% after SVD, 5% after forceps 6-24 wks SVD-30%, VD-34% Abn TRUS 10% vs 27.5% AI- forceps OR=1.3 1 year AI- OVD OR= yrs AI- no diff between groups 6 wks AI- 1% antenatal, 4.9% postpartum.004 NS NS

12 + Operative Vaginal Delivery and OASIS/ Anal incontinence OVD and risk of OASIS Samuelsson, 2000: 2883 deliveries OASIS incidence of 3.3%. VE=10.7% vs SVD=2.9%. OR=4 Wu, 2005: 393 VE. OASIS- OP 41.7%, OA 22% (p=0.003) Groutz, 2011: , deliveries 60 OASIS. Among risk factors, VE with OR=10

13 + Operative Vaginal Delivery and OASIS/ Anal incontinence Minaglia, 2007: vaginal deliveries. OASIS=10.2%

14 + Operative Vaginal Delivery and OASIS/ Anal incontinence Lewis, 2008: case-control study. 358 OASIS, 716 controls

15 + Operative Vaginal Delivery and OASIS- VE vs forceps Author & date N FU results p Johanson, 1999 Weerasekera, VE 115 forceps 204 VE 238 forceps Damron, deliveries Johnson, VE 200 forceps Sheiner, deliveries Bahl, VE 145 forceps 4-5 yrs AI- 26% VE vs 15% forceps NS NR NR NR No difference in OASIS OASIS: VE: OA 26.6%, OP 33.1%. Forceps: OA 53.6%, OP 71.6% OASIS: 44.4% of forceps and 27.9% VE 79 OASIS: 19 (24.1%)after VE and 3 (3.8%) after forceps NR OASIS: 10.9% after VE vs 10.3% after forceps ? NS

16 + Operative Vaginal Delivery and OASIS/ Anal incontinence Sequential Instruments (forceps>>ve) and OASIS De Leeuw, 2001: Dutch national registry ,503 SVD and 46,280 OVD. Overall risk: 1.94%. OR: fundal pressure 1.23, FP+VE 1.64, FP+forceps 3.04, VE 1.79, forceps 2.73, VE+forceps 4.58 Murphy, 2011: 1360 primiparae. Sequential use of instruments: greater maternal morbidity than single instrument use (anal sphincter tear 17.4% versus 8.4%, adjusted OR 2.1, 95% CI )

17 + Operative Vaginal Delivery, OASIS and episiotomy Author & date N FU results p Youssef, OVD NR VE: no epi OR=1.7, epi OR=2.3 Forceps: no epi OR=4.7, epi OR=9.1 De Leeuw, VE 7478 forceps NR 3% VE, 4.7% forceps. Episiotomy: highly protective for OASIS ( VE: OR=0.11, forceps: OR=0.12) Macleod, deliv NR Epi: 9.9%; no epi: 7.1%, adjusted OR= 1.1 Raisanen, VE NR OASIS 3.4% in primiparas. Lateral episiotomy : 46% decreased incidence of OASIS

18 + Operative Vaginal Delivery, OASIS and episiotomy Fitzgerald, 2007: 407 OASIS, 390 no OASIS

19 + Operative Vaginal Delivery, OASIS and episiotomy Kudish, 2008: singleton vertex vaginal deliveries. significant reduction in anal sphincter trauma from 5.4% in 1996 to 1.3% in 2006 and a dramatic drop in the rates of episiotomy and operative vaginal deliveries

20 + Operative Vaginal Delivery is a risk factor for LUTS Author & date N FU results Farrell, mo UI: forceps CS- RR 3, SVD- RR 1.5 Viktrup, yrs VE risk factor with OR=2.9 Arya, VE, 75 f 150 SVD New-onset SUI decreased with time in VE and SVD but not forceps Liebling, OVD vs CS 1 year OVD: greater risk of UI- OR 3.1 Casey, primis 219 dd UUI X2 after forceps (P =.04) Baydock, mo UUI- forceps RF (P = 0.008) Handa, , yrs >OVD: SUI: OR 4.45, ; OAB: OR 4.89 Murphy, OVD UR/UI: seq use OR=3.8. forceps=2.2 Handa, yrs Forceps delivery risk factor for OAB (p=0.006)

21 + Operative Vaginal Delivery is NOT a risk factor for LUTS Author & date N FU results Johanson, pts VE, 115 pts forceps 5 yrs SUI : 7.1% vs 10.4%. No diff in other LUTS Persson, SUI pts > 10 yrs, OR of OVD for SUI surgery 0.78 Meyer, primiparae 10 months No diff in SUI for SVD vs forceps Thompson, 2002 Peschers, pts SVD, 50 pts VE 1193 pts 24 wks No diff in SUI for SVD vs OVD 6-24 wks No difference in LUTS Fritel, pts > 10 yrs OR for forceps 0.8% MacArthur, women 6 yrs OR for forceps 0.99 OR for VE 0.93

22 + Operative Vaginal Delivery and Pelvic Organ Prolapse Author & date N FU results Moalli, 2003 Dannecker, POP 176 cont 26 SVD, 49 VE, 20 nullip forceps delivery OR=3.2 VE vs nullips: decrease in PB length (2.5 cm versus 3.2 cm) Handa, yrs at least one OVD- OR=7.5 Handa, Forceps OR=1.95, VE no incr risk Glazener, yrs Forceps OR=0.64 for POP Uma, POP Forceps OR=0.94 Tegerstedt, 2006 Gyhagen POP No increased risk with OVD history 5199 w 663 POP 20 yrs VE not associated with increased risk of POP

23 + When shall CS for POP and SUI prevention be considered? SUI after SVD Recognized risk factors Advanced maternal age High BMI Diabetes SUI before or during pregnancy or puerperium Increasing number of births Prolonged labor Operative (especially forceps) delivery POP after SVD Recognized risk factors Increasing number of births Operative (especially forceps) delivery

24 + Thank you for your continence!