Birth Trauma. H. P. Dietz. University of Sydney, Nepean Campus. Penrith, Australia

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1 Birth Trauma H. P. Dietz University of Sydney, Nepean Campus Penrith, Australia

2 Procedures in US (2010): 1.6 Prolapse Urinary Incontinence Fecal Incontinence Prolapse Urinary Incontinence Fecal incontinence DeLancey 2012 Since then: PROLONG, SWEPOP... all showing the same.

3 and this is the main reason... 9

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7 Intrapartum Imaging 3D translabial US MR Imaging see also: Shek KL et al. Ultrasound Obstet Gynecol 2015; DOI: /uog.14856

8 Pelvic Floor Ultrasound

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11 Palpation

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13 Tomographic Ultrasound

14 Tomographic Ultrasound -;9 D ,, -;9 D : 97 1,

15 Zhuang et al. AJOG 2011: LUG cut-off 2.34 cm in Asians

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19 Age is a risk factor for maternal birth trauma Figure 1: Estimated probability of A) Any major injury B) Levator ani avulsion C) Hiatal over-distension and D) OASIS, as function of age for each mode of vaginal delivery (n=375). Rahmanou BJOG 2016

20 Avulsion rates in term primiparae:

21 Forceps vs Vacuum: OR for Avulsion

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24 Avulsion is associated with pelvic organ prolapse Author Year Population OR/ RR* Dietz et al sympt. Caucasians, n= 338 (P< 0.001) DeLancey et al sympt. Caucasians, n= 286 OR 7.3 Dietz et al sympt. Caucasians, n= 781 RR Dietz et al sympt. Caucasians, n= 764 (P< 0.001) Rostaminia et al sympt. Caucasians, n= 223 OR Chan et al postpartum Chinese, n= 328? Caudwell Hall et al postpartum Caucasians, n= 844 OR 5.0 Kamisan Atan et al cohort of Caucasians, n= 194 OR 4.9 ( ) Abdool et al sympt. Cauc., Blacks, n=113 (P< 0.001)

25 Avulsion is a risk factor for prolapse recurrence Friedman 2017

26 n=334, mean f.up 2.5 years see also: Svabik et al., UOG 2014;DOI: /uog.13305(43):

27 Reconstruction Reducción del hiato de 39 a 15 cm2, 3 meses luego de la reparación de una avulsión bilateral. Vistas mediosagital (A) y axial (B) en Valsalva antes de una histerectomia abdominal, colposacropexia y reparación de avulsión bilateral; Vista mediosagital (C) y axial (D) en Valsalva 3 meses luego del procedimiento. S= sínfisis del pubis, P= malla Perigee, B= vejiga, U= útero, L= elevador del ano, A= canal anal. Las flechas indican la localización de la reparación del elevador. Dietz 2011

28 and then there is OASIS...

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33 Other recent findings: It s mostly the first baby that does the damage (Kamisan Atan et al., 2015, Subramaniam et al., 2016) EpiNo is not protective (Kamisan Atan et al., 2016) No major improvement over first 2 years (Shek et al., 2016) Palpation is of limited use (Shek et al., 2016) Very low prevalence in Nepalese women after vaginal delivery (Turel et al. 2017) Low likelihood of false positive TUI results using the 4/6 rule (Turel et al. 2017) Defects on TUI better predictor of AI than reported OASIS (>50% missed) (Guzman Rojas et al., 2017)

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38 Forceps vs Vacuum: OR for OASIS (n= forceps, n= vacuum) Friedman 2016

39 We ve seen some interesting changes:

40 A Tale of two Hospitals Incidence of maternal birth trauma in two Sydney tertiary obstetric units ( ), uncomplicated singleton vaginal births at term.

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42 Conclusions- Levator Avulsion is common (10-30%) and may be on the increase due to demographic changes, doubles/ triples the probability of anterior and central compartment prolapse, is associated with prolapse recurrence after surgery (RR 2-4), may require anchored mesh for successful prolapse repair. Forceps is the main obstetric risk factor, with Vacuum much less traumatic.

43 Conclusions- Prolapse Vaginal childbirth is responsible for 80%+ of prolapse (Gyhagen et al., BJOG 2013) Avulsion is the primary etiological factor for cystocele and uterine prolapse. Forceps is the primary modifiable risk factor. Banning Forceps would be expected to reduce the lifetime risk of prolapse sx by >30%. (Lowenstein et al., IUGJ 2015, Lisonkova et al., 2016)

44 Conclusions- OASIS OASIS is the primary modifiable risk factor for fecal incontinence. Forceps is the main modifiable risk factor for OASIS. A 3rd/ 4th degree tear after FD is likely to become indefensible. The effect on FI in later life however is likely to be minor from a statistical/ population health point of view.

45 Conclusions- Maternal birth trauma We need to start treating antenatal patients like adults. That means full informed consent at 36w by an obstetrician/ competent O/G resident and a postnatal debriefing after traumatic childbirth done by medical staff, properly equipped and trained to diagnose major trauma, followed by early intervention with physiotherapy.

46 To become a respected member of the flock you ve got to be... a sheep. Einstein Thank you!