International Urogynecology Journal

, Volume 26, Issue 1, pp 29–32 | Cite as

Pelvic floor and anal sphincter trauma should be key performance indicators of maternity services

  • H. P. Dietz
  • J. Pardey
  • H. Murray
Clinical Opinion


There is an increasing awareness of maternal somatic birth trauma, which affects many more women than previously thought, primarily in the form of anal sphincter and levator ani tears. Given that such trauma occurs in about one-third of all women giving birth vaginally for the first time, and given that it has serious long-term consequences, it should be audited by all maternity services with a view to providing remedial therapy to delay or prevent subsequent morbidity, and to facilitate practice improvement. The increasing availability of modern imaging equipment and the skills of using it for pelvic floor assessment means that it is now becoming possible to provide such services postnatally.


Anal sphincter trauma Levator ani Birth Key performance indicator Birth trauma Pelvic floor 


Financial disclaimer/Conflicts of interest

H.P. Dietz: has received unrestricted educational grants from GE Medical. J. Pardey: nil. H. Murray: nil.


  1. 1.
    Mainz J (2003) Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care 15(6):523–530PubMedCrossRefGoogle Scholar
  2. 2.
    Singh R, Nath Trivedi A (2011) Is the caesarean section rate really a performance indicator of an obstetric unit? J Matern Fetal Neonatal Med 24(2):204–207PubMedCrossRefGoogle Scholar
  3. 3.
    Sufang G, Padmadas S, Fengmin Z, Brown J, Stones R (2007) Delivery settings and caesarean section rates in China. Bull World Health Org 85(10):733–820CrossRefGoogle Scholar
  4. 4.
    Menacker F, Hamilton BE (2010) Recent trends in cesarean delivery in the United States. US Department of Health and Human Services, Washington DC. Accessed 9 Oct 2014
  5. 5.
    American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine (2014) Obstetric care consensus no. 1: Safe prevention of the primary cesarean delivery. Obstet Gynecol 123(3):693–711CrossRefGoogle Scholar
  6. 6.
    Eason E, Labrecque M, Wells G, Feldman P (2000) Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol 95(3):464–471PubMedCrossRefGoogle Scholar
  7. 7.
    Shek K, Dietz H (2010) Intrapartum risk factors of levator trauma. Br J Obstet Gynaecol 117:1485–1492CrossRefGoogle Scholar
  8. 8.
    Cassado Garriga J, Pessarodona Isern A, Espuna Pons M, Duran Retamal M, Felgueroso Fabregas A, Rodriguez-Carballeira M (2011) Tridimensional sonographic anatomical changes on pelvic floor muscle according to the type of delivery. Int Urogynecol J 22:1011–1018PubMedCrossRefGoogle Scholar
  9. 9.
    Chan S, Chung M, Wan O, Cheung R (2013) Levator ani muscle injury after instrumental delivery in Chinese primiparous women. Ultrasound Obstet Gynecol 42(S1):39Google Scholar
  10. 10.
    DeLancey J, Morgan D, Fenner D, Kearney R, Guire K, Miller J, Hussain H, Umek W, Hsu Y, Ashton-Miller J (2007) Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol 109(2):295–302PubMedCrossRefGoogle Scholar
  11. 11.
    Poen AC, Felt-Bersma RJ, Dekker GA, Devillé W, Cuesta MA, Meuwissen SG (1997) Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy. Br J Obstet Gynaecol 104(5):563–566PubMedCrossRefGoogle Scholar
  12. 12.
    MacArthur C, Glazener C, Lancashire R, Herbison GP, Wilson D, Grant AM (2005) Faecal incontinence and mode of first and subsequent delivery: a five year longitudinal study. Br J Obstet Gynaecol 112(8):1075–1082CrossRefGoogle Scholar
  13. 13.
    Andrews V, Sultan AH, Thakar R, Jones PW (2006) Occult anal sphincter injuries – myth or reality? BJOG 113(2):195–200Google Scholar
  14. 14.
    Guzman Rojas R, Shek K, Langer S, Dietz H (2013) Prevalence of anal sphincter injury in primiparous women. Ultrasound Obstet Gynecol 42(4):461–466PubMedGoogle Scholar
  15. 15.
    Dietz HP (2009) Pelvic floor assessment: a review. Fetal Matern Med Rev 20:49–66CrossRefGoogle Scholar
  16. 16.
    Krofta L, Otcenasek M, Kasikova E, Feyereisl J (2009) Pubococcygeus-puborectalis trauma after forceps delivery: evaluation of the levator ani muscle with 3D/4D ultrasound. Int Urogynecol J 20:1175–1181CrossRefGoogle Scholar
  17. 17.
    Alcalay M, Brecher S, Kalter A, Schiff E, Eisenberg V (2011) Different patterns of pelvic floor dysfunction in forceps and vacuum deliveries. Int Urogynecol J 22(S1):S69–S70Google Scholar
  18. 18.
    Dietz H, Lanzarone V (2005) Levator trauma after vaginal delivery. Obstet Gynecol 106:707–712PubMedCrossRefGoogle Scholar
  19. 19.
    Dietz H, Simpson J (2008) Levator trauma is associated with pelvic organ prolapse. Br J Obstet Gynaecol 115:979–984CrossRefGoogle Scholar
  20. 20.
    Dietz HP, Chantarasorn V, Shek KL (2010) Levator avulsion is a risk factor for cystocele recurrence. Ultrasound Obstet Gynecol 36:76–80PubMedCrossRefGoogle Scholar
  21. 21.
    Weemhoff M, Vergeldt T, Notten K, Serroyen J, Kampschoer P, Roumen F (2012) Avulsion of puborectalis muscle and other risk factors for cystocele recurrence: a 2-year follow-up study. Int Urogynecol J 23(1):65–71PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Blasi I, Fuchs I, D'Amico R, Vinci V, La Sala G, Mazza V, Henrich W (2011) Intrapartum translabial three-dimensional ultrasound visualization of levator trauma. Ultrasound Obstet Gynecol 37(1):88–92PubMedCrossRefGoogle Scholar
  23. 23.
    Albrich S, Laterza R, Skala C, Salvatore S, Koelbl H, Naumann G (2012) Impact of mode of delivery on levator morphology: a prospective observational study with 3D ultrasound early in the postpartum period. Br J Obstet Gynaecol 119(1):51–61CrossRefGoogle Scholar
  24. 24.
    Chan S, Cheung R, Yiu A, Lee L, Pang A, Choy K, Leung T, Chung T (2012) Prevalence of levator ani muscle injury in Chinese primiparous women after first delivery. Ultrasound Obstet Gynecol 39(6):704–709PubMedCrossRefGoogle Scholar
  25. 25.
    Leijonhufvud A, Lundholm C, Cnattingius S, Granath F, Andolf E, Altman D (2011) Risks of stress urinary incontinence and pelvic organ prolapse surgery in relation to mode of childbirth. Am J Obstet Gynecol 204(1):70.e71–70.e77CrossRefGoogle Scholar
  26. 26.
    Mant J, Painter R, Vessey M (1997) Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 104(5):579–585PubMedCrossRefGoogle Scholar
  27. 27.
    DeLancey J (2005) The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment. Am J Obstet Gynecol 192:1488–1495PubMedCrossRefGoogle Scholar
  28. 28.
    Glazener C, MacArthur C, Bain C, Dean N, Toozs-Hobson P, Richardson K, Lancashire R, Herbison P, Hagen S, Grant A, Wilson D (2010) Epidemiology of pelvic organ prolapse in relation to delivery mode history at 12 years after childbirth: a longitudinal cohort study. Neurourol Urodyn 29(6):819–820Google Scholar
  29. 29.
    MacArthur C, Glazener C, Lancashire R, Herbison P, Wilson D (2011) Exclusive caesarean section delivery and subsequent urinary and faecal incontinence: a 12-year longitudinal study. Br J Obstet Gynaecol 118(8):1001–1007CrossRefGoogle Scholar
  30. 30.
    Thomas V, Shek K, Guzman Rojas R, Dietz H (2013) The latency between pelvic floor trauma and presentation for prolapse surgery. Ultrasound Obstet Gynecol 42(S1):39Google Scholar
  31. 31.
    Smith F, Holman D, Moorin R, Tsokos N (2010) Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol 116:1096–1100PubMedCrossRefGoogle Scholar
  32. 32.
    Royal College of Obstetricians and Gynaecologists (2008) Good practice no. 7. Maternity Dashboard: clinical performance and governance score card. Royal College of Obstetricians and Gynaecologists, London. Google Scholar
  33. 33.
    Dietz H (2012) Female pelvic floor dysfunction – an imaging perspective. Nat Rev Gastroenterol Hepatol 9:113–121CrossRefGoogle Scholar
  34. 34.
    Brown S, Lumley J (1998) Maternal health after childbirth: results of an Australian population based survey. Br J Obstet Gynaecol 105(2):156–161PubMedCrossRefGoogle Scholar
  35. 35.
    Johnstone SJ, Boyce PM, Hickey AR, Morris-Yatees AD, Harris MG (2001) Obstetric risk factors for postnatal depression in urban and rural community samples. Aust N Z J Psychiatry 35(1):69–74PubMedCrossRefGoogle Scholar
  36. 36.
    Dietz H (2007) Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol 29:329–334PubMedCrossRefGoogle Scholar
  37. 37.
    Dietz H, Shek K, Clarke B (2005) Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol 25:580–585PubMedCrossRefGoogle Scholar

Copyright information

© The International Urogynecological Association 2014

Authors and Affiliations

  1. 1.Sydney Medical School NepeanNepean HospitalPenrithAustralia
  2. 2.Nepean HospitalPenrithAustralia
  3. 3.John Hunter HospitalNewcastleAustralia

Personalised recommendations