Skip to main content
SpringerLink
Log in

Pelvic floor muscle injury during a difficult labor. Can tissue fatigue damage play a role?

  • Clinical Opinion
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

Pubovisceral muscle (PVM) injury during a difficult vaginal delivery leads to pelvic organ prolapse later in life. If one could address how and why the muscle injury originates, one might be able to better prevent these injuries in the future. In a recent review we concluded that many atraumatic injuries of the muscle-tendon unit are consistent with it being weakened by an accumulation of passive tissue damage during repetitive loading. While the PVM can tear due to a single overstretch at the end of the second stage of labor we hypothesize that it can also be weakened by an accumulation of microdamage and then tear after a series of submaximal loading cycles. We conclude that there is strong indirect evidence that low cycle fatigue of PVM passive tissue is a possible mechanism of its proximal failure. This has implications for finding new ways to better prevent PVM injury in the future.

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
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Notes

  1. Note: The term tissue ‘fatigue’ in this context has nothing to do with muscle fatigue, which is a completely different physiological process adversely affecting the ability of muscle to generate contractile force.

  2. For the purpose of this paper, as we shall see, the ‘low’ in low-cycle fatigue refers to between 2 to 120 loading cycles.

  3. As opposed to the high-cycle fatigue failure found in many engineering materials after millions of loading cycles.

  4. Examples of this effect can be seen, for instance, when placing a human hair under too much tension. It then has a tendency to fail at the root, not in mid-shaft. Another example are the suture points from surgical repairs. Different techniques have been developed to reduce the stress concentration between the tissue and the stitches in order to reduce the risk of skin tearing.

  5. Defined as a change in length over the original length

  6. Maximum stress or strain that the material can withstand without failing.

References

  1. Shek KL, Dietz HP. Intrapartum risk factors for levator trauma. BJOG. 2010;117:1485–92. https://doi.org/10.1111/j.1471-0528.2010.02704.x.

    Article  CAS  PubMed  Google Scholar 

  2. Miller JM, Low LK, Zielinski R, et al. Evaluating maternal recovery from labor and delivery: bone and levator ani injuries. Am J Obstet Gynecol 2015;213:188.e1–e11. https://doi.org/10.1016/j.ajog.2015.05.001.

    Article  Google Scholar 

  3. Samuelsson E, Ladfors L, Lindblom BG, Hagberg H. A prospective observational study on tears during vaginal delivery: occurrences and risk factors. Acta Obstet Gynecol Scand. 2002;81:44–9.

    Article  Google Scholar 

  4. DeLancey JOL. What’s new in the functional anatomy of pelvic organ prolapse? Curr Opin Obstet Gynecol. 2016;28:420–9. https://doi.org/10.1097/GCO.0000000000000312.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Laganà AS, La Rosa VL, Rapisarda AMC, Vitale SG. Pelvic organ prolapse: the impact on quality of life and psychological well-being. J Psychosom Obstet Gynecol. 2018;39:164–6. https://doi.org/10.1080/0167482X.2017.1294155.

    Article  Google Scholar 

  6. Ashton-Miller JA, DeLancey JOL. Functional anatomy of the female pelvic floor. Ann N Y Acad Sci. 2007;1101:266–96. https://doi.org/10.1196/annals.1389.034.

    Article  PubMed  Google Scholar 

  7. Vila Pouca MCP, Parente MPL, Natal Jorge RM, Ashton-Miller JA. Injuries in muscle-tendon-bone units: a systematic review considering the role of passive tissue fatigue. Orthop J Sport Med. 2021;9(8):23259671211020731. https://doi.org/10.1177/23259671211020731.

    Article  Google Scholar 

  8. Chen J, Kim J, Shao W, et al. An anterior cruciate ligament failure mechanism. Am J Sports Med. 2019;47:2067–76. https://doi.org/10.1177/0363546519854450.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Lin AH, Allan AN, Zitnay JL, et al. Collagen denaturation is initiated upon tissue yield in both positional and energy-storing tendons. Acta Biomater. 2020;118:153–60. https://doi.org/10.1016/j.actbio.2020.09.056.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Zitnay JL, Jung GS, Lin AH, et al. Accumulation of collagen molecular unfolding is the mechanism of cyclic fatigue damage and failure in collagenous tissues. Sci Adv. 2020;6:eaba2795. https://doi.org/10.1126/sciadv.aba2795.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Sassmannshausen G, Mair SD. Musculotendinous injuries about the athletically active middle-aged knee. Sports Med Arthrosc. 2003;11:107–11. https://doi.org/10.1097/00132585-200311020-00004.

    Article  Google Scholar 

  12. Schechtman H, Bader DL. In vitro fatigue of human tendons. J Biomech. 1997;30:829–35. https://doi.org/10.1016/S0021-9290(97)00033-X.

    Article  CAS  PubMed  Google Scholar 

  13. Andarawis-Puri N, Flatow EL. Tendon fatigue in response to mechanical loading. J Musculoskelet Neuronal Interact. 2011;11:106–14.

    CAS  PubMed  Google Scholar 

  14. Milella PP. Fatigue and corrosion in metals. 1st ed. Milan: Springer-Verlag; 2013.

    Book  Google Scholar 

  15. Leveno KJ, Nelson DB, McIntire DD. Second-stage labor: how long is too long? Am J Obstet Gynecol. 2016;214:484–9. https://doi.org/10.1016/j.ajog.2015.10.926.

    Article  PubMed  Google Scholar 

  16. Lien K-C, DeLancey JOL, Ashton-Miller JA. Biomechanical analyses of the efficacy of patterns of maternal effort on second-stage progress. Obstet Gynecol. 2009;113:873–80. https://doi.org/10.1097/AOG.0b013e31819c82e1.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Lee N, Gao Y, Lotz L, Kildea S. Maternal and neonatal outcomes from a comparison of spontaneous and directed pushing in second stage. Women Birth. 2019;32:e433–40. https://doi.org/10.1016/j.wombi.2018.10.005.

    Article  PubMed  Google Scholar 

  18. Ashton-Miller JA, DeLancey JOL. On the biomechanics of vaginal birth and common sequelae. Annu Rev Biomed Eng. 2009;11:163–76. https://doi.org/10.1146/annurev-bioeng-061008-124823.On.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Tracy PV, Wadhwani S, Triebwasser J, et al. On the variation in maternal birth canal in vivo viscoelastic properties and their effect on the predicted length of active second stage and levator ani tears. J Biomech. 2018;74:64–71. https://doi.org/10.1016/j.jbiomech.2018.04.019.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Rothrauff BB, Tuan RS. Cellular therapy in bone-tendon interface regeneration. Organogenesis. 2014;10:13–28. https://doi.org/10.4161/org.27404.

    Article  PubMed  Google Scholar 

  21. Sevivas N, França G, Oliveira N, et al. Biomaterials for tendon regeneration—. In: Canata GL, d’Hooghe P, Hunt KJ, editors. Muscle and tendon injuries: evaluation and management. Berlin, Heidelberg: Springer; 2017. p. 131–43.

    Chapter  Google Scholar 

  22. VanDusen K, Larkin L. Muscle-tendon interface. In: Regenerative engineering of musculoskeletal tissues and interfaces. Cambridge: Woodhead Publishing; 2015. p. 409–29.

    Chapter  Google Scholar 

  23. Kim J, Betschart C, Ramanah R, et al. Anatomy of the pubovisceral muscle origin: macroscopic and microscopic findings within the injury zone. Neurourol Urodyn. 2015;34:774–80. https://doi.org/10.1002/nau.22649.

    Article  PubMed  Google Scholar 

  24. Zantop T, Brucker PU, Vidal A, et al. Intraarticular rupture pattern of the ACL. Clin Orthop Relat Res. 2007;454:48–53. https://doi.org/10.1097/BLO.0b013e31802ca45b.

    Article  PubMed  Google Scholar 

  25. Lipps DB, Wojtys EM, Ashton-Miller JA. Anterior cruciate ligament fatigue failures in knees subjected to repeated simulated pivot landings. Am J Sports Med. 2013;41:1058–66. https://doi.org/10.1177/0363546513477836.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Stauber T, Blache U, Snedeker JG. Tendon tissue microdamage and the limits of intrinsic repair. Matrix Biol. 2020;85–86:68–79. https://doi.org/10.1016/j.matbio.2019.07.008.

    Article  CAS  PubMed  Google Scholar 

  27. Thorpe CT, Riley GP, Birch HL, et al. Fascicles and the interfascicular matrix show decreased fatigue life with ageing in energy storing tendons. Acta Biomater. 2017;56:58–64. https://doi.org/10.1016/j.actbio.2017.03.024.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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

    Article  Google Scholar 

  29. Noonan TJ, Best TM, Seaber AV, Garrett WEJ. Identification of a threshold for skeletal muscle injury. Am J Sports Med. 1994;22:257–61. https://doi.org/10.1177/036354659402200217.

    Article  CAS  PubMed  Google Scholar 

  30. Taylor DC, Dalton JDJ, Seaber AV, Garrett WEJ. Experimental muscle strain injury. Early functional and structural deficits and the increased risk for reinjury. Am J Sports Med. 1993;21:190–4. https://doi.org/10.1177/036354659302100205.

    Article  CAS  PubMed  Google Scholar 

  31. Yeni YN, Fyhrie DP. Fatigue damage-fracture mechanics interaction in cortical bone. Bone. 2002;30:509–14. https://doi.org/10.1016/S8756-3282(01)00696-2.

    Article  CAS  PubMed  Google Scholar 

  32. Cheng AJ, Jude B, Lanner JT. Intramuscular mechanisms of overtraining. Redox Biol. 2020;35:101480. https://doi.org/10.1016/j.redox.2020.101480.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Miura K. Application of scanning acoustic microscopy to pathological diagnosis. In: Stanciu S, editors Microscopy and analysis. Rijeka: IntechOpen; 2016. p. 381–403.

    Google Scholar 

  34. Miura K, Fukushi Y. Scanning acoustic microscopy imaging of cellular structural and mechanical alterations from external stimuli. Heliyon. 2021;7:e07847. https://doi.org/10.1016/j.heliyon.2021.e07847.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Yu H. Scanning acoustic microscopy for material evaluation. Appl Microsc. 2020;50:25. https://doi.org/10.1186/s42649-020-00045-4.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Da Silva AS, Digesu GA, Dell’Utri C, et al. Do ultrasound findings of levator ani “avulsion” correlate with anatomical findings: a multicenter cadaveric study. Neurourol Urodyn. 2016;35:683–8. https://doi.org/10.1002/nau.22781.

    Article  PubMed  Google Scholar 

  37. Da Silva AS, Asfour V, Digesu GA, et al. Levator ani avulsion: the histological composition of this site. A cadaveric study. Neurourol Urodyn. 2019;38:123–9. https://doi.org/10.1002/nau.23847.

    Article  PubMed  Google Scholar 

  38. Schmidt L, Sobotka T, Bentzen JG, Nyboe Andersen A. Demographic and medical consequences of the postponement of parenthood. Hum Reprod Update. 2012;18:29–43. https://doi.org/10.1093/humupd/dmr040.

    Article  CAS  PubMed  Google Scholar 

  39. Pearse WH. Electronic recording of forceps delivery. Am J Obstet Gynecol. 1963;86:43–51. https://doi.org/10.1016/0002-9378(63)90075-9.

    Article  CAS  PubMed  Google Scholar 

  40. Pina A, Garcia I, Sabater M. Traumatic avulsion of the triceps brachii. J Orthop Trauma. 2002;16:273–6. https://doi.org/10.1097/00005131-200204000-00010.

    Article  CAS  PubMed  Google Scholar 

  41. Lien K-C, Mooney B, DeLancey JOL, Ashton-Miller JA. Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol. 2004;103:31–40. https://doi.org/10.1097/01.AOG.0000109207.22354.65.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Tracy PV, Wineman AS, Orejuela FJ, et al. A constitutive model description of the in vivo material properties of lower birth canal tissue during the first stage of labor. J Mech Behav Biomed Mater. 2018;79:213–8. https://doi.org/10.1016/j.jmbbm.2017.12.025.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors gratefully acknowledge the support from Fundação para a Ciência e Tecnologia (Portugal) under grant SFRH/BD/136213/2018, the funding provided by LAETA (Portugal), under project UIDB/50022/2020, and the US Public Health Service grants 5P30AG024824-15, RC2 DK122379-01 and 5R01AR054821-09.

Author information

Authors and Affiliations

  1. Faculty of Engineering of University of Porto, Porto, Portugal

    Maria C. P. Vila Pouca, Marco P. L. Parente & Renato M. Natal Jorge

  2. Institute of Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal

    Maria C. P. Vila Pouca, Marco P. L. Parente & Renato M. Natal Jorge

  3. Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA

    John O. L. DeLancey

  4. Departments of Mechanical and Biomedical Engineering, College of Engineering, University of Michigan, Ann Arbor, MI, USA

    James A. Ashton-Miller

Authors
  1. Maria C. P. Vila Pouca
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marco P. L. Parente
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Renato M. Natal Jorge
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. John O. L. DeLancey
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. James A. Ashton-Miller
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

M.C.P. Vila Pouca: conceived the presented idea, manuscript writing; M.P.L. Parente: supervised the work, manuscript editing; R.M. Natal Jorge: supervised the work, manuscript editing; J.O.L. DeLancey: conceived the presented idea, supervised the work, manuscript editing; J.A. Ashton-Miller: conceived the presented idea, supervised the work, manuscript writing.

Corresponding author

Correspondence to Maria C. P. Vila Pouca.

Ethics declarations

Conflicts of interests

M.C.P.V.P., M.P.L.P. and R.M.N.J. declare no conflicts of interest. J.O.L.D. and J.A.A-M.’s institution received US National Institutes of Health Grant R44 HD 096987 for them to analyze the Materna LLC Prep device data on the relationship between birth canal dilation force and displacement during the first stage of labor.

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

Vila Pouca, M.C.P., Parente, M.P.L., Natal Jorge, R.M. et al. Pelvic floor muscle injury during a difficult labor. Can tissue fatigue damage play a role?. Int Urogynecol J 33, 211–220 (2022). https://doi.org/10.1007/s00192-021-05012-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00192-021-05012-5

Keywords

Search

Navigation