Abstract
Episiotomy is still a controversy issue among physicians, despite the enormous growth of clinical research. Therefore, the potential of numerical modeling of anatomical structures to simulate biomechanical processes was exploited to realize quantitatively the real effects of the episiotomy and its consequences on the pelvic floor muscle. As such, a numerical model was used composed of pelvic floor muscles, a surface delimiting the anterior region, and a fetus body. A normal vaginal delivery without and with different episiotomies was simulated with the fetus in vertex presentation and occipitoanterior position. According to our numerical results, a mediolateral episiotomy has a protective effect, reducing the stress on the muscles, and the force required to delivery successfully up to 52.2 %. The intervention also has benefits on muscle injury, reducing the damage to a small zone. This study demonstrates the feasibility of using a computational modeling approach to study parturition, namely the capability to isolate and evaluate the mechanical significance of a single feature. It must, however, be taken into account that the numerical model does not assess problems that may occur as blood loss, infections and others, so it is necessary to examine whether the benefits of an intervention outweigh the risks.
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References
Ashton-Miller JA, Delancey JOL (2009) On the biomechanics of vaginal birth and common sequelae. Annu Rev Biomed Eng 11:163–176. doi:10.1146/annurev-bioeng-061008-124823
Benzley SE, Perry E, Merkley K et al (1995) A comparison of all-hexahedral and all-tetrahedral finite element meshes for elastic and elasto-plastic analysis. In: 4th international meshing roundtable, Sandia National Laboratories, pp 179–191
Bielser D, Glardon P, Teschner M, Gross M (2004) A state machine for real-time cutting of tetrahedral meshes. Graph Models 66:398–417. doi:10.1016/j.gmod.2004.05.009
Borges BB, Serrano F, Pereira F (2003) Episiotomia: Uso generalizado versus selectivo. Acta Med Port 16:447–454
Brandão S, Parente M, Mascarenhas T et al (2015) Biomechanical study on the bladder neck and urethral positions: simulation of impairment of the pelvic ligaments. J Biomech 48:217–223. doi:10.1016/j.jbiomech.2014.11.045
Buttin R, Zara F, Shariat B et al (2013) Biomechanical simulation of the fetal descent without imposed theoretical trajectory. Comput Methods Programs Biomed 111:389–401. doi:10.1016/j.cmpb.2013.04.005
Calvo B, Peña E, Martinez MA, Doblaré M (2007) An uncoupled directional damage model for fibred biological soft tissues. Formulation and computational aspects. Int J Numer Methods Eng 69:2036–2057. doi:10.1002/nme.1825
Carroli G, Belizan J (2007) Episiotomy for vaginal birth (Review). Cochrane Libr 1–56. doi:10.1002/14651858.CD000081.pub2.Copyright
D’Aulignac D, Martins JAC, Pires EB et al (2005) A shell finite element model of the pelvic floor muscles. Comput Methods Biomech Biomed Eng 8:339–347. doi:10.1080/10255840500405378
DeLancey JOL, Kearney R, Chou Q et al (2003) The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 101:46–53. doi:10.1016/S0029-7844(02)02465-1
Dietz HP (2013) Pelvic floor trauma in childbirth. Aust N Z J Obstet Gynaecol 53:220–230. doi:10.1111/ajo.12059
Durnea CM, O’Reilly BA, Khashan AS et al (2015) Status of the pelvic floor in young primiparous women. Ultrasound Obstet Gynecol 46:356–362. doi:10.1002/uog.14711
Eogan M, Daly L, O’Connell PR, O’Herlihy C (2006) Does the angle of episiotomy affect the incidence of anal sphincter injury? BJOG Int J Obstet Gynaecol 113:190–194. doi:10.1111/j.1471-0528.2005.00835.x
Friedman S, Blomquist J, Nugent J (2012) Pelvic muscle strength after childbirth. Obstet Gynecol 120:1021–1028. doi:10.1097/AOG.0b013e318265de39
Garrett W, Seaber A, Boswick J et al (1984) Recovery of skeletal muscle after laceration and repair. J Hand Surg 9:683–692
Hale RW, Ling FW (2007) Episiotomy—procedure and repair techniques
Handa VL, Blomquist JL, McDermott KC et al (2012) Pelvic floor disorders after vaginal birth: effect of episiotomy, perineal laceration, and operative birth. Obstet Gynecol 119:233–239. doi:10.1097/AOG.0b013e318240df4f
Hartmann K, Viswanathan M, Palmieri R et al (2005) Outcomes of routine episiotomy—a systematic review. J Am Med Assoc 293:2141–2148. doi:10.1001/jama.293.17.2141
Helewa ME (1997) Episiotomy and severe perineal trauma. Of science and fiction. Can Med Assoc J 156:811–813
Humphrey JD (2001) Cardiovascular solid mechanics—cells, tissues, and organs. Springer, Texas
Janda Š, van der Helm FCT, de Blok SB (2003) Measuring morphological parameters of the pelvic floor for finite element modelling purposes. J Biomech 36:749–757. doi:10.1016/S0021-9290(03)00008-3
Jeřábková L, Bousquet G, Barbier S et al (2010) Volumetric modeling and interactive cutting of deformable bodies. Prog Biophys Mol Biol 103:217–224. doi:10.1016/j.pbiomolbio.2010.09.012
Kalis V, Laine K, De Leeuw JW et al (2012) Classification of episiotomy: towards a standardisation of terminology. BJOG An Int J Obstet Gynaecol 119:522–526. doi:10.1111/j.1471-0528.2011.03268.x
Kalis V, Landsmanova J, Bednarova B et al (2011) Evaluation of the incision angle of mediolateral episiotomy at 60 degrees. Int J Gynecol Obstet 112:220–224. doi:10.1016/j.ijgo.2010.09.015
Karbanova J, Landsmanova J, Novotny Z (2009) Angle of mediolateral episiotomy using the ischial tuberosity as a reference point. Int J Gynecol Obstet 107:157. doi:10.1016/j.ijgo.2009.05.025
Kearney R, Miller JM, Ashton-Miller JA, DeLancey JOL (2006) Obstetric factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol 107:144–149. doi:10.1097/01.AOG.0000194063.63206.1c
Klein M, Gauthier R, Robbins J et al (1994) Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol 171:591–598
Li X, Kruger JA, Nash MP, Nielsen PMF (2010) Effects of nonlinear muscle elasticity on pelvic floor mechanics during vaginal childbirth. J Biomech Eng 132:111010. doi:10.1115/1.4002558
Lindblad A, Turkiyyah G (2007) A physically-based framework for real-time haptic cutting and interaction with 3D continuum models. In: Proceedings of the SPM 2007 ACM Symp Solid Phys Model 1, pp 421–429. doi:10.1145/1236246.1236307
Llewellyn-Jones D (2010) Fundamentals of obstetrics and gynaecology, 9th edn. MOSBY Elsevier, London
Martins JAC, Pato MPM, Pires EB et al (2007) Finite element studies of the deformation of the pelvic floor. Ann N Y Acad Sci 1101:316–334. doi:10.1196/annals.1389.019
Melo I, Katz L, Coutinho I, Amorim M (2014) Selective episiotomy vs. implementation of a non episiotomy protocol: a randomized clinical trial. Reprod Health 11:66. doi:10.1186/1742-4755-11-66
Myers-Helfgott M, Helfgott A (1999) Routine use of episiotomy in modern obstetrics. Should it be performed? Obs Gynecol Clin N Am 26:305–325
Parente MP, Jorge RMN, Mascarenhas T, Silva-Filho AL (2010a) The influence of pelvic muscle activation during vaginal delivery. Obstet Gynecol 115:804–808. doi:10.1097/AOG.0b013e3181d534cd
Parente MPL (2008) Biomechanics of the pelvic floor during vaginal delivery. University of Porto, Faculty of Engineering
Parente MPL, Jorge RMN, Mascarenhas T et al (2008) Deformation of the pelvic floor muscles during a vaginal delivery. Int Urogynecol J Pelvic Floor Dysfunct 19:65–71. doi:10.1007/s00192-007-0388-7
Parente MPL, Jorge RMN, Mascarenhas T et al (2009) The influence of the material properties on the biomechanical behavior of the pelvic floor muscles during vaginal delivery. J Biomech 42:1301–1306. doi:10.1016/j.jbiomech.2009.03.011
Parente MPL, Jorge RMN, Mascarenhas T et al (2010) Computational modeling approach to study the effects of fetal head flexion during vaginal delivery. Am J Obstet Gynecol 203:217.e1–217.e6. doi:10.1016/j.ajog.2010.03.038
Peña E, Calvo B, Martínez MA, Doblaré M (2008) On finite-strain damage of viscoelastic-fibred materials. Application to soft biological tissues. Int J Numer Methods Eng 74:1198–1218. doi:10.1002/nme.2212
Plowman SA, Smith DL (2011) Exercise physiology—for health, fitness, and performance, 3rd edn. Wolters Kluwer Health - Lippincott Williams & Wilkins, Baltimore
Ramos A, Simões JA (2006) Tetrahedral versus hexahedral finite elements in numerical modelling of the proximal femur. Med Eng Phys 28:916–924. doi:10.1016/j.medengphy.2005.12.006
Ranney B (1990) Decreasing numbers of patients for vaginal hysterectomy and plasty. S D J Med 43:7–12
Silva MET, Oliveira DA, Roza TH et al (2015) Study on the influence of the fetus head molding on the biomechanical behavior of the pelvic floor muscles, during vaginal delivery. J Biomech 1–6: doi:10.1016/j.jbiomech.2015.02.032
Simo JC (1987) On a fully three-dimensional finite-strain viscoelastic damage model: formulation and computational aspects. Comput Methods Appl Mech Eng 60:153–173. doi:10.1016/0045-7825(87)90107-1
Sooklim R, Thinkhamrop J, Lumbiganon P et al (2007) The outcomes of midline versus medio-lateral episiotomy. Reprod Health 4:10–15. doi:10.1186/1742-4755-4-10
Tayrac R, Panel L, Masson G, Mares P (2006) L’épisiotomie—Épisiotomie et prévention des lésions pelvi-périnéales. J Gynecol Obs Biol Reprod 35:1S24–1S31
Verspyck E, Sentilhes L, Roman H et al (2006) Recommandations pour la pratique clinique Techniques chirurgicales de l ’ épisiotomie. Biol Reprod 35:40–51
Viswanathan M, Hartmann K, Palmieri R et al (2005) The use of episiotomy in obstetrical care: a systematic review. Evid Rep Technol Assess 112:1–8
Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen K (2015) Pelvic organ prolapse and incontinence 15–23 years after first delivery: a cross-sectional study. BJOG Int J Obstet Gynaecol 122:964–971. doi:10.1111/1471-0528.13322
Acknowledgments
This research was supported by the Portuguese Foundation of Science and Technology under Grants SFRH/BD/80110/2011 and IF/00159/2014, and research project UID/EMS/50022/2013.
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Oliveira, D.A., Parente, M.P.L., Calvo, B. et al. A biomechanical analysis on the impact of episiotomy during childbirth. Biomech Model Mechanobiol 15, 1523–1534 (2016). https://doi.org/10.1007/s10237-016-0781-6
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DOI: https://doi.org/10.1007/s10237-016-0781-6