Does the Epi-No® Birth Trainer reduce levator trauma? A randomised controlled trial


Introduction and hypothesis

The purpose of this study is to evaluate whether antepartum use of a birth trainer may reduce levator trauma.


Two hundred nulliparous women were examined with four-dimensional translabial ultrasonography at 35–37 weeks of gestation and 3 months postpartum in a randomised controlled pilot study. Women in the intervention group were instructed to use the birth trainer from 37 weeks onwards.


One hundred forty-six women returned for follow-up 5.6 months (range 2.3–22.1) after childbirth. Seventy-eight of them had had normal vaginal deliveries (53%), 32 vacuum/forceps (22%) and 36 a caesarean section (25%). The risk of avulsion was halved in the intervention group (6% vs 13%, P = 0.19) on modified intention to treat analysis. A treatment received analysis revealed a nonsignificant 42% and 30% reduction in levator avulsion and microtrauma, respectively (P ≥ 0.22).


This pilot randomised controlled trial showed a nonsignificantly lower incidence of pelvic floor muscle injury in women who used the Epi-No® device from 37 weeks onwards.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. 1.

    Lien KC, Mooney B, DeLancey JO, Ashton-Miller JA (2004) Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol 103(1):31–40

    PubMed  Article  Google Scholar 

  2. 2.

    Svabik K, Shek KL, Dietz HP (2009) How much does the levator hiatus have to stretch during childbirth? BJOG 116:1657–1662

    PubMed  Article  CAS  Google Scholar 

  3. 3.

    Dietz HP, Lanzarone V (2005) Levator trauma after vaginal delivery. Obstet Gynecol 106(4):707–712

    PubMed  Article  Google Scholar 

  4. 4.

    Krofta L, Otcenasek M, Kasikova E, Feyereisl J (2009) Pubococcygeus-puborectalis trauma after forecps delivery: evaluation of the levator ani muscle with 3D/4D ultrasound. Int Urogynecol J 20:1175–1181

    Article  Google Scholar 

  5. 5.

    Shek KL, Dietz HP (2009) The effect of childbirth on hiatal dimensions. Obstet Gynecol 113(6):1272–1278

    PubMed  Google Scholar 

  6. 6.

    Toozs-Hobson P, Balmforth J, Cardozo L, Khullar V, Athanasiou S (2008) The effect of mode of delivery on pelvic floor functional anatomy. Int Urogynecol J 19:407–416

    Article  Google Scholar 

  7. 7.

    Broos SV, Zerba E, Faulkner JA (1995) Injury to muscle fibres after single stretches of passive and maximally stimulated muscles in mice. J Physiol 488(2):459–469

    Google Scholar 

  8. 8.

    Jou I, Lai K, Shen C, Yamano Y (2000) Changes in conduction, blood flow, histology and neurological status following acute nerve-stretch injury induced by femoral lengthening. J Ortho Res 18:149–155

    Article  CAS  Google Scholar 

  9. 9.

    Dietz HP, Shek C, De Leon J, Steensma AB (2008) Ballooning of the levator hiatus. Ultrasound Obstet Gynecol 31(6):676–680

    PubMed  Article  CAS  Google Scholar 

  10. 10.

    Dietz HP, Simpson JM (2007) Does delayed child-bearing increase the risk of levator injury in labour? Aust NZ J OG 47(6):491–495

    Google Scholar 

  11. 11.

    DeLancey JOLMD, Morgan DMMD, Fenner DEMD, Kearney RMD, Guire KMS, Miller JMPA et al (2007) Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol 109(2, Part 1):295–302

    PubMed  Article  Google Scholar 

  12. 12.

    Adekanmi OA, Freeman R, Puckett M, Jackson S (2005) Cystocele: does anterior repair fail because we fail to correct the fascial defects? A clinical and radiological study. Int Urogynecol J 16:S73

    Article  Google Scholar 

  13. 13.

    Hillebrenner J, Wagenpfeil S, Schuchardt R, Schelling M, Schneider T (2000) First clinical experiences with the new birth trainer Epi-no® in primiparous women. Z Geburtsh Neonatol 204:1–8

    Article  Google Scholar 

  14. 14.

    Kovacs G, Heath P, Heather C (2004) First Australian trial of the birth-training device Epi-No: a highly significantly increased chance of an intact perineum. Aust NZ J OG 44:347–348

    Google Scholar 

  15. 15.

    McHugh M, Cosgrave C (2010) To stretch of not to stretch: the role of stretching in injury prevention and performance. Scand J Med Sci Sports 20:169–181

    PubMed  CAS  Google Scholar 

  16. 16.

    Dietz HP (2004) Ultrasound imaging of the pelvic floor. Part II: three-dimensional or volume imaging. Ultrasound Obstet Gynecol 23:615–625

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    Dietz HP, Shek C, Clarke B (2005) Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol 25(6):580–585

    PubMed  Article  CAS  Google Scholar 

  18. 18.

    Yang JM, Yang SH, Huang WC (2006) Biometry of the pubovisceral muscle and levator hiatus in nulliparous Chinese women. Ultrasound Obstet Gynecol 28:710–716

    PubMed  Article  Google Scholar 

  19. 19.

    Kruger JA, Dietz HP, Murphy BA (2007) Pelvic floor function in elite nulliparous athletes. Ultrasound Obstet Gynecol 30(1):81–85

    PubMed  Article  CAS  Google Scholar 

  20. 20.

    Shek K, Dietz H (2010) Intrapartum risk factors for levator trauma. BJOG 117:1485–1492

    PubMed  Article  CAS  Google Scholar 

  21. 21.

    Dietz HP (2007) Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol 29(3):329–334

    PubMed  Article  CAS  Google Scholar 

  22. 22.

    Dietz H, Shek K (2009) Tomographic ultrasound of the pelvic floor: which levels matter most? Ultrasound Obstet Gynecol 33:698–703

    PubMed  Article  CAS  Google Scholar 

  23. 23.

    Weinstein MM, Pretorius D, Nager CW, Mittal R (2007) Inter-rater reliability of pelvic floor muscle imaging abnormalities with 3D ultrasound. Ultrasound Obstet Gynecol 30(4):538

    Article  Google Scholar 

  24. 24.

    Dietz H, Steensma A (2006) The prevalence of major abnormalities of the levator ani in urogynaecological patients. BJOG 113(2):225–230

    PubMed  Article  CAS  Google Scholar 

  25. 25.

    Shek K, Dietz H (2010) Can levator avulsion be predicted antenatally? Am J Obstet Gynecol. doi:10.1016/j.ajog.2009.11.038

  26. 26.

    Valsky D, Lipschuetz M, Bord A, Eldar I, Messing B, Hochner-Celnikier D et al (2009) Fetal head circumference and length of second stage of labour are risk factors for levator ani muscle injury, diagnosed by 3-dimensional transperineal ultrasound in primiparous women. Am J Obstet Gynecol 201(91):e1–e7

    PubMed  Google Scholar 

  27. 27.

    Brooks S, Zebra E, Faulkner J (1995) Injury to the muscle fibres after single stretches of passive and maximally stimulated muscle in mice. J Physio 488(2):459–469

    CAS  Google Scholar 

  28. 28.

    Weppler C, Magnusson S (2010) Increasing muscle extensibility: a matter of increasing length or modifying sensation? Phys Ther 90:438–449

    PubMed  Article  Google Scholar 

  29. 29.

    Ingeborg H, Majida M, Engh M, Bo K (2010) Morphological changes after pelvic floor muscle training measured by 3-Dimenisonal ultrasonography. A randomized controlled trial. Obstet Gynecol 115:317–324

    Article  Google Scholar 

  30. 30.

    King JK, Freeman RM (1998) Is antenatal bladder neck mobility a risk factor for postpartum stress incontinence? BJOG 105(12):1300–1307

    Article  CAS  Google Scholar 

Download references


The Epi-No® Birth Trainer was donated by the Starnberg Medical, Tecsana GMBH, Muenchen, Germany.

Conflict of interest statement

KL Shek, V Chantarasorn, S Langer and H Phipps have no conflict of interest to declare. HP Dietz has acted as a consultant for AMS (American Medical Systems) and CCS (Continence Control Systems); has accepted Speaker’s fees from GE (General Electric), AMS and Astellas and has benefited from equipment loans provided by GE, Bruel and Kjaer and Toshiba.

Author information



Corresponding author

Correspondence to Ka Lai Shek.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Shek, K.L., Chantarasorn, V., Langer, S. et al. Does the Epi-No® Birth Trainer reduce levator trauma? A randomised controlled trial. Int Urogynecol J 22, 1521–1528 (2011).

Download citation


  • Childbirth
  • Epi-No birth trainer
  • Levator avulsion
  • Levator microtrauma
  • Pelvic organ prolapse
  • Ultrasound