Childbirth and pelvic floor trauma

doi:10.1016/j.bpobgyn.2005.08.009

Best Practice & Research Clinical Obstetrics & Gynaecology

Volume 19, Issue 6, December 2005, Pages 913-924

https://doi.org/10.1016/j.bpobgyn.2005.08.009 Get rights and content

The issue of traumatic damage to the pelvic floor in childbirth is attracting more and more attention amongst obstetric caregivers and laypersons alike. This is partly due to the fact that elective caesarean section as a potentially preventative intervention is increasingly available and perceived as safe. As there is a multitude of emotive issues involved, including health economics and the relative roles of healthcare providers, the discussion surrounding pelvic floor trauma in childbirth has not always been completely rational. However, after 25 years of urogynaecological research in this field it should be possible to determine whether pelvic floor trauma in childbirth is myth or reality, and, if real, whether it matters for the pathogenesis of incontinence and prolapse. On reviewing the available evidence, it appears that there are sufficient grounds to assume that vaginal delivery (or even the attempt at vaginal delivery) can cause damage to the pudendal nerve, the inferior aspects of the levator ani muscle and fascial pelvic organ supports. Risk factors for such damage have been defined and variously include operative vaginal delivery, a long second stage, and macrosomia. It is much less clear, however, whether such trauma is clinically relevant, and how important it is in the aetiology of pelvic floor morbidity later in life.

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

References (55)

M.E. Carley et al.
Obstetric history in women with surgically corrected adult urinary incontinence or pelvic organ prolapse
J Am Assoc Gynecol Laparosc
(1999)
A.L. Olsen et al.
Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence
Obstet Gynecol
(1997)
J.A. Adashek et al.
Factors contributing to the increased cesarean birth rate in older parturient women
Am J Obstet Gynecol
(1993)
S. Bewley et al.
The unfacts of request caesarean section
Br J Obstet Gynaecol
(2002)
S. Bewley et al.
The unethics of request caesarean section
Br J Obstet Gynaecol
(2002)
C. Klutke et al.
The anatomy of stress incontinence: magnetic resonance imaging of the female bladder neck and urethra
J Urol
(1990)
L. Hoyte et al.
Two- and 3-dimensional MRI comparison of levator ani structure, volume, and integrity in women with stress incontinence and prolapse
Am J Obstet Gynecol
(2001)
J.L. Ecker et al.
Increased risk of cesarean delivery with advancing maternal age: indications and associated factors in nulliparous women
Am J Obstet Gynecol
(2001)
F. Chiaffarino et al.
Reproductive factors, family history, occupation and risk of urogenital prolapse
Eur J Obstet Gynecol Reprod Biol
(1999)
C.M. Sampselle
Changes in pelvic muscle strength and stress urinary incontinence associated with childbirth
J Obstet Gynecol Neonat Nurs
(1990)

R.C. Bump et al.

The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction

Am J Obstet Gynecol

(1996)

S.E. Swift

The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care

Am J Obstet Gynecol

(2000)

U. Peschers et al.

Changes in vesical neck mobility following vaginal delivery

Obstet Gynecol

(1996)

S. Meyer et al.

The effects of birth on urinary continence mechanisms and other pelvic-floor characteristics

Obstet Gynecol

(1998)

H.P. Dietz et al.

The effect of childbirth on pelvic organ mobility

Obstet Gynecol

(2003)

H.P. Dietz et al.

Pelvic organ descent in young nulligravid women

Am J Obstet Gynecol

(2004)

H.P. Dietz et al.

Which women are most affected by delivery-related changes in pelvic organ mobility?

Eur J Obstet Gynecol Reprod Biol

(2003)

E.H.M. Sze et al.

Pregnancy, labour, delivery and pelvic organ prolapse

Obstet Gynecol

(2002)

J.L. Ecker

Once a pregnancy, always a cesarean? Rationale and feasibility of a randomized controlled trial

Am J Obstet Gynecol

(2004)

N.M. Fisk

Caesarean section for all patients?

H. Minkoff et al.

Elective primary cesarean delivery.[comment]

New Engl J Med

(2003)

A.H. MacLennan et al.

The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery

Br J Obstet Gynaecol

(2000)

T.K. Young et al.

Factors that are associated with cesarean delivery in a large private practice: the importance of prepregnancy body mass index and weight gain

Am J Obstet Gynecol

(2002)

P.D. Wilson et al.

Obstetric practice and urinary incontinence 5–7 years after delivery

Neurourol Urodyn

(2002)

G. Rortveit et al.

Urinary incontinence after vaginal delivery or cesarean section.[comment]

New Engl J Med

(2003)

G.W. Davila

Informed consent for obstetrics management: a urogynecologic perspective. [Review] [16 refs]

Int Urogynecol J

(2001)

R.E. Allen et al.

Pelvic floor damage and childbirth: a neurophysiological study

Br J Obstet Gynaecol

(1990)

Cited by (71)

Description and classification of postpartum chronic pain: A multicentric prospective study
2020, Journal of Gynecology Obstetrics and Human Reproduction
Citation 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.
To classify persistent perineal and pelvic postpartum pain using the classification usually employed in chronic pelvic pain.
Prospective observational study including all women who have consulted an algologist or gynecologist at one of the six French centers for a chronic pain (superior or equal to 3 months) spontaneous linked by the mother with her childbirth were included. During semi-directed interviews, a questionnaire regarding sociodemographic factors and detailed questions about pain were collected. Then, pelvic and perineal pain were classified into 7 pain syndromes: pelvic sensitization (Convergences PP criteria), complex regional pain syndrome (Budapest criteria), pudendal or cluneal neuralgia (Nantes criteria), neuroma, thoraco-lumbar junction syndrome, myofascial pain (muscle trigger zone), fibromyalgia (American College of Rheumatology criteria). The principal objective of this study is to assess the prevalence of each painful disorder. The secondary aims were the description of socio-demographic factors and clinical characteristics of this population, identify the related symptoms and the impact on daily function associated with the chronic pelvic or perineal postpartum pain.
40 women with chronic pelvic or perineal pain spontaneously linked with childbirth were included. 78 % experienced pain for more than 12 months. A large majority had a vaginal birth (95 %) with perineal suture (90 %) and severe acute pain within the first week postpartum (62 %). Postpartum pain impacted participant’s sexual activity (80 %), micturition (28 %) and defecation (38 %). In the sample, 17 cases of neuroma, 6 patients with pudendal or cluneal neuralgia, 13 patients with pelvic sensitization and 2 cases of fibromyalgia were identified. Complex regional pain syndrome was diagnosed in 8 patients, and myofascial pain in 11 women, and only 1 patient had thoraco-lumbar junction syndrome. Neuropathic pain was found in 31 participants (77.5 %) according to DN4 criteria.
The classification scheme proposed in this study may be a very useful tool to investigate postpartum pelvic and perineal pain and to propose a treatment.
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 Practice
To evaluate the effects of gestational diabetes mellitus (GDM) on the structural characteristics of the rectus abdominis muscle (RAM) and its indirect effects on pregnancy-specific urinary incontinence (PSUI).
A total of 92 pregnant women were divided into four groups, according to their clinical conditions: non-GDM continent, non-GDM associated PSUI, GDM continent and GDM associated PSUI. The muscle morphometry (histochemistry and immunohistochemistry) for the fiber types and collagen fiber distribution, the ultrastructural analysis (transmission electron microscopy), the protein expression of fiber types and calcium signaling (Western blotting), and the content of types I and III collagen fiber (ELISA) in RAM collected at delivery were assessed.
The GDM groups presented a significantly increased number of slow fibers and slow-twitch oxidative fiber expression; decreased fiber area, number of fast fibers, and area of collagen; an increase in central nuclei; ultrastructural alterations with focal lesion areas such as myeloid structures, sarcomere disorganization, and mitochondrial alteration. The PSUI groups presented a considerable decrease in types I and III collagen contents and the localization of collagen fiber.
Our data reveal that GDM causes morphological, biochemical and physiological changes in the RAM, and this might predispose women to PSUI.
Childbirth pelvic floor trauma: Anatomy, physiology, pathophysiology and special situations – CNGOF perineal prevention and protection in obstetrics guidelines
2018, Gynecologie Obstetrique Fertilite et Senologie
Évaluer si la taille et la forme du bassin, la statique rachidienne, la brièveté anatomique périnéale et les dimensions du hiatus génital sont des éléments anatomiques associés à l’apparition de lésions pelvipérinéales obstétricales. Certaines situations particulières, comme l’obésité, l’ethnie et l’hyperlaxité seront également étudiées.
Une recherche bibliographique à l’aide des bases de données Pubmed et de la Cochrane Library a été réalisée jusqu’en mai 2018. Les publications en langues anglaise et française ont été sélectionnées par lecture initiale des abstracts. Les essais randomisés, les méta-analyses, les études cas-témoins et les grandes cohortes ont été étudiées de manière privilégiée.
Un angle sous-pubien < 90° (mesuré cliniquement) ne semble pas augmenter pas le risque de LOSA (NP3), mais semble être un facteur de risque d’incontinence anale postnatale à court terme, mais pas à long terme (NP3). En l’absence d’étude spécifique, il n’est pas actuellement possible de dire s’il existe une association entre une hyperlordose lombaire pendant la grossesse et la survenue de lésions pelvipérinéales obstétricales. Les mesures prénatales de la distance anovulvaire (NP3) et du hiatus génital (NP2) ne permettent pas de prédire la survenue d’une lésion périnéale obstétricale du 2^e ou du 3^e degré. La désinsertion (« avulsion ») du faisceau puborectal du muscle releveur, ayant pour conséquence un élargissement du hiatus génital, est potentiellement pourvoyeuse de dysfonctions pelvipérinéales à long-terme. Les modèles biomécaniques semblent indiquer que la réalisation d’une épisiotomie médiolatérale et que l’apposition des doigts sur le périnée postérieur au moment de l’expulsion peuvent réduire les lésions musculaires pelvipérinéales. Les femmes obèses auraient une distance anovulvaire plus longue (NP3) et l’obésité ne semble pas augmenter les risques de LOSA (NP2). Il n’y a pas de différence entre la longueur périnéale des femmes asiatiques et les femmes non asiatiques (NP3). Aucune étude n’a validé que la pratique libérale de l’épisiotomie chez les patientes asiatiques permettait de réduire le risque de LOSA. Il n’est donc pas recommandé de pratiquer une épisiotomie pour simple raison ethnique chez les femmes asiatiques (Grade C). Par rapport aux femmes blanches, les femmes noires ne semblent pas avoir un risque augmenté de LOSA et semblent même avoir un risque diminué de lésions périnéales de tous stades (NP2). L’augmentation de la laxité ligamentaire semble être associée à un risqué augmenté de LOSA (NP2).
Les évaluations prénatales du bassin, de la statique rachidienne, de la distance anovulvaire et du hiatus génital ne permettent pas de prédire la survenue de lésions pelvipérinéales obstétricales. L’obésité et l’ethnie ne sont pas des facteurs de risque de LOSA.
To assess whether pelvic size and shape, spinal curvature, perineal body length and genital hiatus size are associated with the incidence of childbirth pelvic floor trauma. Special situations, such as obesity, ethnicity and hyperlaxity, will also be studied.
A bibliographic research using Pubmed and Cochrane Library databases was conducted until May 2018. Publications in English and French were selected by initial reading of the abstracts. Randomized trials, meta-analyzes, case-control studies and large cohorts were studied in a privileged way.
A pubic arch angle < 90° (measured clinically) does not appear to increase the risk of OASIS (Level 3), but appears to be a risk factor for postnatal anal incontinence at short-term, but not at long-term (Level 3). Measurement of pelvic dimensions and the subpubic angle is not recommended to predict OASIS or to choose the mode of delivery for the purpose of protecting the perineum (Grade C). Prenatal measurement of both perineal body (Level 3) and genital hiatus (Level 2) does not predict the incidence of 2nd or 3rd degree OASIS. Therefore, the routine prenatal measurement of the length of the perineal body or the genital hiatus is not recommended for any objective related to perineal protection (Grade C). Levator avulsion, resulting in a widening of the genital hiatus, is potentially a source of long-term pelvic floor dysfunction. Biomechanical models suggest that performing a mediolateral episiotomy and applying the fingers to the posterior perineum at the time of expulsive phase may reduce pelvic floor trauma. Obese women have a longer perineal body (Level 3), and obesity does not seem to increase the risk of OASIS (Level 2). There is no difference between Asian and non-Asian women perineal body (Level 3). No studies have validated that the liberal practice of episiotomy in Asian women reduced the risk of OASIS. It is therefore not recommended to practice an episiotomy for simple ethnic reasons in Asian women (Grade C). Compared to white women, black women do not appear to have an increased risk of OASIS and even appear to have a decreased risk of perineal tears of all stages (Level 2). Ligament hyperlaxity seems to be associated with an increased risk of OASIS (Level 2).
Prenatal assessment of pelvis bone, spine curvature, perineal body and genital hiatus do not allow to predict the incidence of childbirth pelvic floor trauma. Obesity and ethnicity are not risk factors for OASIS.
Pelvic muscles’ mechanical response to strains in the absence and presence of pregnancy-induced adaptations in a rat model
2018, American Journal of Obstetrics and Gynecology
Citation 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
Maternal birth trauma to the pelvic floor muscles is thought to be consequent to mechanical demands placed on these muscles during fetal delivery that exceed muscle physiological limits. The above is consistent with studies of striated limb muscles that identify hyperelongation of sarcomeres, the functional muscle units, as the primary cause of mechanical muscle injury and resultant muscle dysfunction. However, pelvic floor muscles’ mechanical response to strains have not been examined at a tissue level. Furthermore, we have previously demonstrated that during pregnancy, rat pelvic floor muscles acquire structural and functional adaptations in preparation for delivery, which likely protect against mechanical muscle injury by attenuating the strain effect.
We sought to determine the mechanical impact of parturition-related strains on pelvic floor muscles’ microstructure, and test the hypothesis that pregnancy-induced adaptations modulate muscle response to strains associated with vaginal delivery.
Three-month-old Sprague-Dawley late-pregnant (N = 20) and nonpregnant (N = 22) rats underwent vaginal distention, replicating fetal crowning, with variable distention volumes. Age-matched uninjured pregnant and nonpregnant rats served as respective controls. After sacrifice, pelvic floor muscles, which include coccygeus, iliocaudalis, and pubocaudalis, were fixed in situ and harvested for fiber and sarcomere length measurements. To ascertain the extent of physiological strains during spontaneous vaginal delivery, analogous measurements were obtained in intrapartum rats (N = 4) sacrificed during fetal delivery. Data were compared with repeated measures and 2-way analysis of variance, followed by pairwise comparisons, with significance set at P < .05.
Gross anatomic changes were observed in the pelvic floor muscles following vaginal distention, particularly in the entheseal region of pubocaudalis, which appeared translucent. The above appearance resulted from dramatic stretch of the myofibers, as indicated by significantly longer fiber length compared to controls. Stretch ratios, calculated as fiber length after vaginal distention divided by baseline fiber length, increased gradually with increasing distention volume. Paralleling these macroscopic changes, vaginal distention resulted in acute and progressive increase in sarcomere length with rising distention volume. The magnitude of strain effect varied by muscle, with the greatest sarcomere elongation observed in coccygeus, followed by pubocaudalis, and a smaller increase in iliocaudalis, observed only at higher distention volumes. The average fetal rat volume approximated 3 mL. Pelvic floor muscle sarcomere lengths in pregnant animals undergoing vaginal distention with 3 mL were similar to intrapartum sarcomere lengths in all muscles (P > .4), supporting the validity of our experimental approach. Vaginal distention resulted in dramatically longer sarcomere lengths in nonpregnant compared to pregnant animals, especially in coccygeus and pubocaudalis (P < .0001), indicating significant attenuation of sarcomere elongation in the presence of pregnancy-induced adaptations in pelvic floor muscles.
Delivery-related strains lead to acute sarcomere elongation, a well-established cause of mechanical injury in skeletal muscles. Sarcomere hyperelongation resultant from mechanical strains is attenuated by pregnancy-induced adaptations acquired by the pelvic floor muscles prior to parturition.
The Epidemiology of Pelvic Floor Disorders and Childbirth. An Update.
2016, Obstetrics and Gynecology Clinics of North America
Citation 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 Reproduction
Citation 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].
Pelvic floor muscle training (PFMT) is the first step of treatment for stress urinary incontinence (SUI). Patients must perform self-retraining exercises of the perineal muscles at home in order to maintain the benefit of the physiotherapy. The aim of this study is to assess the benefit of a perineal electro-stimulator, using three-dimensional ultrasound, during this home-care phase.
A longitudinal prospective study was conducted between May 2012 and May 2013. All patients with de novo SUI benefited from PFMT followed by a self-maintenance of perineal rehabilitation at home with the Keat^® Pro system. The primary endpoint was the biometric of the levator ani and it was assessed by three-dimensional perineal ultrasound at inclusion, after conventional rehabilitation and at the end of the study after self-rehabilitation.
Ten patients were included. All patients (100%) showed a clinical improvement of SUI. The quality of life was significantly improved after PFMT vs. inclusion (P = 0.014) and after self-rehabilitation vs. after PFMT (P = 0.033). Levator ani muscles were significantly thicker after conventional rehabilitation than at baseline (P = 0.004) and significantly thicker after self-rehabilitation than after PFMT (P = 0.009).
Conducting self-rehabilitation in addition to conventional PFMT objectively improves the perineal muscle building achieved after conventional rehabilitation.
Le traitement de première intention de l’incontinence urinaire d’effort (IUE) chez la femme est la rééducation périnéosphincterienne (RPS). Des dispositifs d’électrostimulation périnéale à domicile permettent aux patientes de réaliser une rééducation « d’entretien » visant à maintenir le bénéfice de la RPS initiale. Le but de cette étude est de mettre en évidence le bénéfice de cette réeducation d’entretien par électrostimulation en utilisant l’échographie périnéale tridimensionnelle (3D).
Dans cette étude longitudinale prospective réalisée entre mai 2012 et mai 2013, les patientes incluses ont bénéficiées d’une RPS (10 séances) suivie d’une rééducation d’entretien à l’aide du système Keat Pro^®. Le critère de jugement principal était l’épaisseur du muscle Elevator Ani mesurée en échographie périnéale 3D à l’inclusion, après la RPS et après la réeducation d’entretien.
Dix patientes ont été incluses. En fin de protocole, toutes les patientes (100 %) ont présenté une amélioration clinique. Les scores de qualité de vie étaient significativement améliorés en fin de protocole par rapport à l’évaluation initiale (17,9 vs 10,3, p = 0,02). Le muscle Elevator Ani était significativement plus épais après RPS qu’à l’inclusion (p = 0,01) et après la rééducation d’entretien qu’après RPS (p = 0,01).
La réalisation d’une rééducation d’entretien en complément d’une RPS permet d’augmenter le renforcement périnéal obtenu après la rééducation conventionnelle.

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7Childbirth and pelvic floor trauma

Section snippets

Adverse effects on nerve structure and function

Adverse effects on pelvic floor muscle structure and function

Adverse effects on pelvic organ support

Clinical significance: The epidemiological evidence

Conclusion

J Am Assoc Gynecol Laparosc

Obstet Gynecol

Am J Obstet Gynecol

Br J Obstet Gynaecol

Br J Obstet Gynaecol

J Urol

Am J Obstet Gynecol

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

J Obstet Gynecol Neonat Nurs

Am J Obstet Gynecol

Am J Obstet Gynecol

Obstet Gynecol

Obstet Gynecol

Obstet Gynecol

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Obstet Gynecol

Am J Obstet Gynecol

Caesarean section for all patients?

Elective primary cesarean delivery.[comment]

New Engl J Med

The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery

Br J Obstet Gynaecol

Factors that are associated with cesarean delivery in a large private practice: the importance of prepregnancy body mass index and weight gain

Am J Obstet Gynecol

Obstetric practice and urinary incontinence 5–7 years after delivery

Neurourol Urodyn

Urinary incontinence after vaginal delivery or cesarean section.[comment]

New Engl J Med

Informed consent for obstetrics management: a urogynecologic perspective. [Review] [16 refs]

Int Urogynecol J

Pelvic floor damage and childbirth: a neurophysiological study

Br J Obstet Gynaecol

7
Childbirth and pelvic floor trauma