Best Practice & Research Clinical Obstetrics & Gynaecology
7Childbirth and pelvic floor trauma
Section snippets
Adverse effects on nerve structure and function
It has been postulated that labour and vaginal delivery, and in particular the second stage of labour, may have a negative effect on nervous structures supplying pelvic organs and the pelvic floor. While this may also be true for the autonomic innervation of bladder and anorectum, the best-investigated structure in this regard is the pudendal nerve and its branches. Due to its location and ease of access to innervated structures such as the pubococcygeus–puborectalis complex and the anal
Adverse effects on pelvic floor muscle structure and function
What we call the ‘pelvic floor’ is, to a large extent, the pubococcygeus-puborectalis complex. This muscle complex forms a v-shaped sling running from the pelvic sidewall on one side, posteriorly around the anorectal junction, and back towards the contralateral pelvic sidewall. The levator hiatus, i.e. the space between the arms of the V, contains the urethra anteriorly, the vagina centrally and the anorectum posteriorly (see Figure 1 for a comparison of MRI and ultrasound imaging of the
Adverse effects on pelvic organ support
Clinical studies of pelvic organ support were until recently limited by a lack of sufficiently sensitive tools for prolapse assessment. This has changed with the introduction of the POP-Q system for prolapse quantification introduced by the International Continence Society.42 Parity seems to be a risk factor for pelvic organ prolapse as defined by the POP-Q assessment43, but data are scarce due to the fact that even such a simple assessment is invasive and less well tolerated in pregnancy and
Clinical significance: The epidemiological evidence
While there is a growing body of evidence supporting the contention that childbirth often has a deleterious effect on pelvic floor structures, the long latency of symptoms related to pelvic floor morbidity impede studies into the clinical relevance of delivery-related changes. Epidemiological studies are often much more equivocal than the pathophysiological findings described above, as the aetiology of prolapse and urinary and faecal incontinence is clearly multifactorial, and as the importance
Conclusion
There is little doubt that some women suffer significant trauma to pelvic floor structures as a consequence of (successful or unsuccessful) attempts at vaginal childbirth. Trauma may affect the pudendal nerve or its branches, the anal sphincter, the puborectalis–pubococcygeus complex, and/or pelvic fascial structures. The more protracted a delivery is and the longer the duration of second stage, the higher the likelihood of anatomical or functional alteration. Vaginal operative delivery seems
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Cited by (71)
Description and classification of postpartum chronic pain: A multicentric prospective study
2020, Journal of Gynecology Obstetrics and Human ReproductionCitation Excerpt :The classification scheme proposed in this study is easy to use and can decrease medical wandering and a patient’s impression of incurability. Pudendal nerve injury can be caused by childbirth [15,16] and seems to be mostly found after a long second stage of labor, a third degree perineal tear, forceps delivery or a high birth weight [17]. However, pudendal nerve trauma during childbirth is not directly responsible for pain.
Deleterious effects of gestational diabetes mellitus on the characteristics of the rectus abdominis muscle associated with pregnancy-specific urinary incontinence
2020, Diabetes Research and Clinical PracticeChildbirth pelvic floor trauma: Anatomy, physiology, pathophysiology and special situations – CNGOF perineal prevention and protection in obstetrics guidelines
2018, Gynecologie Obstetrique Fertilite et SenologiePelvic muscles’ mechanical response to strains in the absence and presence of pregnancy-induced adaptations in a rat model
2018, American Journal of Obstetrics and GynecologyCitation Excerpt :This protective effect, which is greatest at the distention volume corresponding to average fetal size, is diminished at higher strains, indicating a potential tipping point beyond which pregnancy-induced adaptations are no longer sufficient to protect pelvic floor muscles against birth injury. The pathways by which vaginal delivery leads to pelvic floor disorders are believed to be multifactorial, involving damage to nerves,1-3 connective tissue,4-7 and pelvic smooth and striated muscles.8-10 Clinical studies suggest that maternal trauma to the pelvic floor muscles (PFMs) results from mechanical demands imposed on these muscles during parturition that exceed skeletal muscle physiological limits.9
The Epidemiology of Pelvic Floor Disorders and Childbirth. An Update.
2016, Obstetrics and Gynecology Clinics of North AmericaCitation Excerpt :One potential mechanism may be damage to the levator ani muscle (LAM). The work of Delancey38–40 and Dietz and colleagues41–43 has done much to draw attention to the role of levator tears in the development of PFDs. The LAM can be injured by stretch (overdistension, or microtrauma) or avulsion (disruption of the muscle, or macrotrauma).44
Impact of at-home self-rehabilitation of the perineum on pelvic floor function in patients with stress urinary incontinence: Results from a prospective study using three-dimensional ultrasound
2016, Journal de Gynecologie Obstetrique et Biologie de la ReproductionCitation Excerpt :Although some studies have reported on the potential use of 3D-US in pelvic floor disorders such as perineal postpartum injuries, pelvic organ prolapse or UI, to date, no study has investigated the effect of a combined rehabilitation (PFMT plus self-rehabilitation at home) by 3D-US. At rest, the levator hiatus has a mean area of 11.4 cm2 (range: 6–36) on nulliparous and 14.6 cm2 on multiparous women [14,15]. The size of the urogenital hiatus has been previously shown to be associated with pelvic floor disorders such as pelvic organ prolapse by several studies [16,17].