Advertisement

International Urogynecology Journal

, Volume 29, Issue 3, pp 369–375 | Cite as

The impact of childbirth on pelvic floor morphology in primiparous Black South African women: a prospective longitudinal observational study

  • Zeelha Abdool
  • Barend G. Lindeque
  • Hans P. Dietz
Original Article
  • 170 Downloads

Abstract

Introduction and hypothesis

There is a lack of prospective studies evaluating the impact of childbirth on the pelvic floor in non-white populations. We intended to study delivery-related changes in pelvic floor morphology in Black South African primiparae. We also intended to determine the impact of anatomical changes on symptoms in the postpartum period.

Methods

A total of 153 nulliparous women between 35 and 39 weeks gestation were recruited from a district antenatal clinic. All women had a standardized interview, completed the International Consultation on Incontinence Vaginal Symptoms questionnaire followed by three/four dimensional transperineal ultrasonography. This was repeated at 3–6 months postpartum.

Results

Of the 153 women, 84 (54.9%) returned at a mean of 4.8 months postpartum. Of these women, 60 (71.4%) had a vaginal delivery and the remainder a caesarean section (20 emergency and 4 elective). Overall, there were statistically significant increases in bladder neck descent (P = 0.003), pelvic organ descent and levator hiatal distensibility (all P < 0001) at the postpartum assessment. Levator avulsion was diagnosed in nine (15%) of those delivered vaginally. Postpartum vaginal laxity was the commonest bothersome vaginal symptom, reported by 51 women (60.7%).

Conclusions

There is significant alteration in pelvic organ support and levator hiatal distensibility postpartum, with more marked effects in women after vaginal delivery. Of Black primiparous women, 15% sustained levator trauma after their first vaginal delivery.

Keywords

Childbirth Pelvic floor morphology Pelvic floor ultrasonography 

Notes

Acknowledgements

We thank Ms. Susan Terblanch B.Com (Hons. Statistics), OLSPS Analytics (Pty) Ltd., South Africa, for assistance with the statistical analysis.

Compliance with ethical standards

Conflicts of interest

Z. Abdool: none.

B.G. Lindeque: none.

H.P. Dietz: unrestricted educational grants from GE Medical.

References

  1. 1.
    Dietz H, Simpson J (2008) Levator trauma is associated with pelvic organ prolapse. Br J Obstet Gynaecol 115:979–984CrossRefGoogle Scholar
  2. 2.
    DeLancey JO, Morgan DM, Fenner DE, Kearney R, Guire K, Miller JM et al (2007) Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol 109:295–302CrossRefPubMedGoogle Scholar
  3. 3.
    Gainey HL (1955) Postpartum observation of pelvic tissue damage: further studies. Am J Obstet Gynecol 70(4):800–807CrossRefPubMedGoogle Scholar
  4. 4.
    Dietz HP, Lanzarone V (2005) Levator trauma after vaginal delivery. Obstet Gynecol 106(4):707–712CrossRefPubMedGoogle Scholar
  5. 5.
    Dietz HP, Shek C, De Leon J, Steensma A (2008) Ballooning of the levator hiatus. Ultrasound Obstet Gynecol 31(6):676–680CrossRefPubMedGoogle Scholar
  6. 6.
    Dietz HP, Bhalla R, Chantarasorn V, Shek KL (2011) Avulsion of the puborectalis muscle is associated with asymmetry of the levator hiatus. Ultrasound Obstet Gynecol 37(6):723–726CrossRefPubMedGoogle Scholar
  7. 7.
    Shek KL, Dietz HP (2009) The effect of childbirth on hiatal dimensions. Obstet Gynecol 113(6):1272–1278CrossRefPubMedGoogle Scholar
  8. 8.
    van Delft K, Sultan AH, Thakar R, Schwertner-Tiepelmann N, Kluivers K (2014) The relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction. BJOG 121(9):1164–1171CrossRefPubMedGoogle Scholar
  9. 9.
    Chan SS, Cheung RY, Yiu AK, Lee LL, Pang AW, Choy KW et al (2012) Prevalence of levator ani muscle injury in Chinese primiparous women after first delivery. Ultrasound Obstet Gynecol 39:704–709CrossRefPubMedGoogle Scholar
  10. 10.
    Chan SS, Cheung RY, Yiu KW, Lee LL, Chung TK (2014) Pelvic floor biometry of Chinese primiparous women 1 year after delivery: a prospective observational study. Ultrasound Obstet Gynecol 43:466–474CrossRefPubMedGoogle Scholar
  11. 11.
    Shek K, Krause H, Wong V, Goh J, Dietz H (2015) Is pelvic organ support different between young nulliparous African and Caucasian women? Ultrasound Obstet Gynecol 47(6):774–778CrossRefGoogle Scholar
  12. 12.
    Abdool Z, Dietz HP, Lindeque GB (2017) Ethnic differences in the levator hiatus and pelvic organ descent: a prospective observational study. Ultrasound Obstet Gynecol 50(2):242–246CrossRefPubMedGoogle Scholar
  13. 13.
    Cheung RY, Shek KL, Chan SS, Chung TK, Dietz HP (2015) Difference in pelvic floor biometry and pelvic organ mobility in Asian and Caucasians nulliparous women. Ultrasound Obstet Gynecol 45:599–604CrossRefPubMedGoogle Scholar
  14. 14.
    Skinner D, Crichton D (1963) Stress incontinence: a comparative racial study. Med Proc 9:189–194Google Scholar
  15. 15.
    Knobel J (1975) Stress incontinence in the black female. S Afr Med J 49:430–432PubMedGoogle Scholar
  16. 16.
    Price N, Jackson SR, Avery K, Brookes ST, Abrams P (2006) Development and psychometric evaluation of the ICIQ vaginal symptoms questionnaire: the ICIQ-VS. BJOG 113(6):700–712CrossRefPubMedGoogle Scholar
  17. 17.
    Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P et al (1996) The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 175(1):10–17CrossRefPubMedGoogle Scholar
  18. 18.
    Örnö A, Dietz H (2007) Levator co-activation is a significant confounder of pelvic organ descent on valsalva maneuver. Ultrasound Obstet Gynecol 30(3):346–350CrossRefPubMedGoogle Scholar
  19. 19.
    Dietz HP (2004) Ultrasound imaging of the pelvic floor. Part I: two-dimensional aspects. Ultrasound Obstet Gynecol 23(1):80–92CrossRefPubMedGoogle Scholar
  20. 20.
    Dietz HP (2004) Ultrasound imaging of the pelvic floor. Part II: three-dimensional or volume imaging. Ultrasound Obstet Gynecol 23(6):615–625CrossRefPubMedGoogle Scholar
  21. 21.
    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):580–585CrossRefPubMedGoogle Scholar
  22. 22.
    Dietz HP (2007) Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol 29(3):329–334CrossRefPubMedGoogle Scholar
  23. 23.
    Tan L, Shek KL, Atan IK, Rojas RG, Dietz HP (2015) The repeatability of sonographic measures of functional pelvic floor anatomy. Int Urogynecol J Pelvic Floor Dysfunct 26(11):1667–1672CrossRefGoogle Scholar
  24. 24.
    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 three-dimensional ultrasound early in the postpartum period. BJOG 119(1):51–61CrossRefPubMedGoogle Scholar
  25. 25.
    Lien KC, Mooney B, DeLancey JO, Ashton-Miller JA (2004) Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol 103(1):31–40CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Zhuang RR, Song YF, Chen ZQ, Ma M, Huang HJ, Chen JH et al (2011) Levator avulsion using a tomographic ultrasound and magnetic resonance–based model. Am J Obstet Gynecol 205(3):232.e1–232.e8CrossRefGoogle Scholar
  27. 27.
    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 Pelvic Floor Dysfunct 19:407–416CrossRefPubMedGoogle Scholar
  28. 28.
    Pauls RN, Fellner AN, Davila GW (2012) Vaginal laxity: a poorly understood quality of life problem; a survey of physician members of the International Urogynecological Association (IUGA). Int Urogynecol J 23(10):1435–1448CrossRefPubMedGoogle Scholar
  29. 29.
    Kingsberg S, Millheiser L (2010) Vaginal laxity after childbirth: qualitative survey of women’s perceptions, effect on changes in self-image and sexual relationships. J Sex Med 7(Suppl 3):127–128Google Scholar
  30. 30.
    Pardo JS, Sola VD, Ricci PA et al (2006) Colpoperineoplasty in women with a sensation of a wide vagina. Acta Obstet Gynecol Scand 85(9):1125–1127CrossRefPubMedGoogle Scholar
  31. 31.
    Hosseini L, Iran-Pour E, Safarinejad MR (2012) Sexual function of primiparous women after elective cesarean section and normal vaginal delivery. Urol J 9(2):498–504PubMedGoogle Scholar
  32. 32.
    Robinson D, Wadsworth S, Cardozo L, Bidmead J, Balmforth J (2003) Fascial posterior colpoperineorrhaphy: a five-year follow-up study. J Pelvic Med Surg 9:279–283CrossRefGoogle Scholar
  33. 33.
    Thibault-Gagnon S, Yusuf S, Langer S, Wong V, Shek KL, Martin A et al (2014) Do women notice the impact of childbirth-related levator trauma on pelvic floor and sexual function? Results of an observational ultrasound study. Int Urogynecol J Pelvic Floor Dysfunct 25(10):1389–1398CrossRefGoogle Scholar
  34. 34.
    Ferreira CW, Atan IK, Martin A, Shek KL, Dietz HP (2017) Pelvic organ support several years after a first birth. Int Urogynecol J Pelvic Floor Dysfunct 28(10):1499–1505CrossRefGoogle Scholar

Copyright information

© The International Urogynecological Association 2017

Authors and Affiliations

  1. 1.Division of Urogynaecology, Department of Obstetrics and GynaecologyUniversity of Pretoria, Steve Biko Academic Hospital, Level 7PretoriaSouth Africa
  2. 2.Department of Obstetrics and GynaecologyUniversity of Sydney Medical School NepeanKingswoodAustralia

Personalised recommendations