Skip to main content
SpringerLink
Log in

Prediction of levator ani muscle avulsion by genital tears after vaginal birth—a prospective observational cohort study

  • Original Article
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

Introduction

Visible birth tears and levator ani muscle (LAM) trauma are common after birth. For the diagnosis of LAM trauma ultrasound evaluation is advisable. As ultrasound equipment and trained personnel are not available everywhere at all times, we aimed to evaluate whether specific overt birth tears are an indicator for LAM trauma.

Methods

In a prospective cohort study at our center from March 2017–April 2019, we evaluated vaginal births of nulliparous women with singletons in vertex presentation ≥ 36 + 0 gestational weeks for LAM trauma by translabial ultrasound and for overt birth tears by inspection. We then calculated the association of overt birth tears with complete LAM avulsion.

Results

Of 213 women, 23.9% had any kind of LAM trauma, with 14.1% being complete avulsions. In univariate analysis, solely high-grade perineal tears (OASIS) were significantly associated with complete LAM avulsions.

Conclusions

Fourteen percent of women suffered a complete LAM avulsion after vaginal birth, with OASIS being the only associated parameter of significance. The occurrence of such trauma might be an indicator for a mismatch between the size of the fetus and the structures of the birth canal, leading to birth trauma. Assessing for LAM trauma by translabial ultrasound in women with OASIS might be worthwhile.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Birri J, Kreft M, Zimmermann R, Kimmich N. [Association of birth trauma with the implementation of obstetrical monitoring tools: a retrospective cohort Study]. Z Geburtshilfe Neonatol. 2018.

  2. Kimmich N, Grauwiler V, Richter A, Zimmermann R, Kreft M. Birth lacerations in different genital compartments and their effect on maternal subjective outcome: a prospective observational study. Z Geburtshilfe Neonatol. 2019.

  3. Wang H, Jayasekara R, Warland J. The effect of "hands on" techniques on obstetric perineal laceration: a structured review of the literature. Women Birth. 2015;28(3):194–8.

    Google Scholar 

  4. Aabakke AJ, Willer H, Krebs L. The effect of maneuvers for shoulder delivery on perineal trauma: a randomized controlled trial. Acta Obstet Gynecol Scand. 2016;95(9):1070–7.

    Google Scholar 

  5. Albers L, Garcia J, Renfrew M, McCandlish R, Elbourne D. Distribution of genital tract trauma in childbirth and related postnatal pain. Birth. 1999;26(1):11–7.

    CAS  Google Scholar 

  6. Ventolini G, Yaklic JL, Galloway ML, Hampton M, Maher JE. Obstetric vulvar lacerations and postpartum dyspareunia. J Reprod Med. 2014;59(11–12):560–5.

    Google Scholar 

  7. Practice Bulletin No. 165. Prevention and management of obstetric lacerations at vaginal delivery. Obstet Gynecol. 2016;128(1):e1–e15.

    Google Scholar 

  8. Smith LA, Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy Childbirth. 2013;13:59.

    Google Scholar 

  9. van Delft K, Thakar R, Sultan AH, Schwertner-Tiepelmann N, Kluivers K. Levator ani muscle avulsion during childbirth: a risk prediction model. BJOG. 2014;121(9):1155–63 discussion 63.

    Google Scholar 

  10. van Delft KW, Thakar R, Sultan AH, IntHout J, Kluivers KB. The natural history of levator avulsion one year following childbirth: a prospective study. BJOG. 2015;122(9):1266–73.

    Google Scholar 

  11. Dietz HP. Pelvic floor trauma in childbirth. Aust N Z J Obstet Gynaecol. 2013;53(3):220–30.

    Google Scholar 

  12. Shek KL, Dietz HP. Intrapartum risk factors for levator trauma. BJOG. 2010;117(12):1485–92.

    CAS  Google Scholar 

  13. Kearney R, Fitzpatrick M, Brennan S, Behan M, Miller J, Keane D, et al. Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery. Int J Gynaecol Obstet 2010;111(1):19–22.

  14. Dietz HP, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol. 2005;106(4):707–12.

    Google Scholar 

  15. Dietz HP. Ultrasound imaging of the pelvic floor. Part II: three-dimensional or volume imaging. Ultrasound Obstet Gynecol. 2004;23(6):615–25.

    CAS  Google Scholar 

  16. Dietz HP, Bernardo MJ, Kirby A, Shek KL. Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J. 2011;22(6):699–704.

    Google Scholar 

  17. Kimmich N, Yeo A, Zimmermann R, Furrer E. How do sustained birth tears after vaginal birth affect birth tear patterns in a subsequent birth? accepted for publication in Journal of Perinatal Medicine. 2020.

  18. Dietz HP, Schierlitz L. Pelvic floor trauma in childbirth—myth or reality? Aust N Z J Obstet Gynaecol. 2005;45(1):3–11.

    CAS  Google Scholar 

  19. Hals E, Oian P, Pirhonen T, Gissler M, Hjelle S, Nilsen EB, et al. A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol. 2010;116(4):901–8.

    Google Scholar 

  20. Kamisan Atan I, Gerges B, Shek KL, Dietz HP. The association between vaginal parity and hiatal dimensions: a retrospective observational study in a tertiary urogynaecological Centre. BJOG. 2015;122(6):867–72.

    CAS  Google Scholar 

  21. Horak TA, Guzman-Rojas RA, Shek KL, Dietz HP. Pelvic floor trauma: does the second baby matter? Ultrasound Obstet Gynecol. 2014;44(1):90–4.

    CAS  Google Scholar 

  22. Valsky DV, Lipschuetz M, Bord A, Eldar I, Messing B, Hochner-Celnikier D, et al. Fetal head circumference and length of second stage of labor are risk factors for levator ani muscle injury, diagnosed by 3-dimensional transperineal ultrasound in primiparous women. Am J Obstet Gynecol. 2009;201(1):91–e1-7.

    Google Scholar 

  23. Kearney R, Miller JM, Ashton-Miller JA, DeLancey JO. Obstetric factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol. 2006;107(1):144–9.

    Google Scholar 

  24. Radestad I, Olsson A, Nissen E, Rubertsson C. Tears in the vagina, perineum, sphincter ani, and rectum and first sexual intercourse after childbirth: a nationwide follow-up. Birth. 2008;35(2):98–106.

    Google Scholar 

  25. Skinner EM, Dietz HP. Psychological and somatic sequelae of traumatic vaginal delivery: a literature review. Aust N Z J Obstet Gynaecol. 2015;55(4):309–14.

    Google Scholar 

  26. Dannecker C, Lienemann A, Fischer T, Anthuber C. Influence of spontaneous and instrumental vaginal delivery on objective measures of pelvic organ support: assessment with the pelvic organ prolapse quantification (POPQ) technique and functional cine magnetic resonance imaging. Eur J Obstet Gynecol Reprod Biol. 2004;115(1):32–8.

    Google Scholar 

  27. Kimmich N, Burkhardt T, Kreft M, Zimmermann R. Reducing birth trauma by the implementation of novel monitoring and documentation tools. Acta Obstet Gynecol Scand. 2019;98(10):1223–6.

    Google Scholar 

  28. Dietz HP, Moegni F, Shek KL. Diagnosis of levator avulsion injury: a comparison of three methods. Ultrasound Obstet Gynecol. 2012;40(6):693–8.

    CAS  Google Scholar 

  29. Dietz HP, Gillespie AV, Phadke P. Avulsion of the pubovisceral muscle associated with large vaginal tear after normal vaginal delivery at term. Aust N Z J Obstet Gynaecol. 2007;47(4):341–4.

    Google Scholar 

  30. Shek KL, Green K, Hall J, Guzman-Rojas R, Dietz HP. Perineal and vaginal tears are clinical markers for occult levator ani trauma. A retrospective observational study. Ultrasound Obstet Gynecol. 2015.

  31. Valsky DV, Cohen SM, Lipschuetz M, Hochner-Celnikier D, Daum H, Yagel I, et al. Third- or fourth-degree intrapartum anal sphincter tears are associated with levator ani avulsion in primiparas. J Ultrasound Med. 2016;35(4):709–15.

    Google Scholar 

Download references

Acknowledgments

There are no acknowledgements.

Funding

The study was supported by GE Healthcare, Zipf, Austria, by providing the ultrasound device (Voluson S10) and probes for the ultrasound examinations during the whole study period.

The Heartbay Foundation (Vaduz, Liechtenstein) supported the project financially.

Author information

Authors and Affiliations

  1. Division of Obstetrics, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland

    Nina Kimmich, Jana Birri, Roland Zimmermann & Martina Kreft

Authors
  1. Nina Kimmich
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jana Birri
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Roland Zimmermann
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Martina Kreft
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nina Kimmich.

Ethics declarations

Conflict of interest

None.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kimmich, N., Birri, J., Zimmermann, R. et al. Prediction of levator ani muscle avulsion by genital tears after vaginal birth—a prospective observational cohort study. Int Urogynecol J 31, 2361–2366 (2020). https://doi.org/10.1007/s00192-020-04297-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00192-020-04297-2

Keywords

Search

Navigation