Joan L. Blomquist

Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth.

OBJECTIVE: To estimate differences in pelvic floor disorders by mode of delivery. METHODS: We recruited 1,011 women for a longitudinal cohort study 5–10 years after first delivery. Using hospital records, we classified each birth as: cesarean without labor, cesarean during active labor, cesarean after complete cervical dilation, spontaneous vaginal birth, or operative vaginal birth. At enrollment, stress incontinence, overactive bladder, anal incontinence, and prolapse symptoms were assessed with a validated questionnaire. Pelvic organ support was assessed using the Pelvic Organ Prolapse Quantification system. Logistic regression analysis was used to estimate the relative odds of each pelvic floor disorder by obstetric history, adjusting for relevant confounders. RESULTS: Compared with cesarean without labor, spontaneous vaginal birth was associated with a significantly greater odds of stress incontinence (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.5–5.5) and prolapse to or beyond the hymen (OR 5.6, 95% CI 2.2–14.7). Operative vaginal birth significantly increased the odds for all pelvic floor disorders, especially prolapse (OR 7.5, 95% CI 2.7–20.9). These results suggest that 6.8 additional operative births or 8.9 spontaneous vaginal births, relative to cesarean births, would lead to one additional case of prolapse. Among women delivering exclusively by cesarean, neither active labor nor complete cervical dilation increased the odds for any pelvic floor disorder considered, although the study had less than 80% power to detect a doubling of the odds with these exposures. CONCLUSION: Although spontaneous vaginal delivery was significantly associated with stress incontinence and prolapse, the most dramatic risk was associated with operative vaginal birth. LEVEL OF EVIDENCE: II

Pelvic Floor Disorders After Vaginal Birth Effect of Episiotomy, Perineal Laceration, and Operative Birth

OBJECTIVE: To investigate whether episiotomy, perineal laceration, and operative delivery are associated with pelvic floor disorders after vaginal childbirth. METHODS: This is a planned analysis of data for a cohort study of pelvic floor disorders. Participants who had experienced at least one vaginal birth were recruited 5–10 years after delivery of their first child. Obstetric exposures were classified by review of hospital records. At enrollment, pelvic floor outcomes, including stress incontinence, overactive bladder, anal incontinence, and prolapse symptoms were assessed with a validated questionnaire. Pelvic organ support was assessed using the Pelvic Organ Prolapse Quantification system. Logistic regression analysis was used to estimate the relative odds of each pelvic floor disorder by obstetric history, adjusting for relevant confounders. RESULTS: Of 449 participants, 71 (16%) had stress incontinence, 45 (10%) had overactive bladder, 56 (12%) had anal incontinence, 19 (4%) had prolapse symptoms, and 64 (14%) had prolapse to or beyond the hymen on examination. Forceps delivery increased the odds of each pelvic floor disorder considered, especially overactive bladder (odds ratio [OR] 2.92, 95% confidence interval [CI] 1.44–5.93), and prolapse (OR 1.95, 95% CI 1.03–3.70). Episiotomy was not associated with any of these pelvic floor disorders. In contrast, women with a history of more than one spontaneous perineal laceration were significantly more likely to have prolapse to or beyond the hymen (OR 2.34, 95% CI 1.13–4.86). Our multivariable results suggest that one additional woman would have development of prolapse for every eight women who experienced at least one forceps birth (compared with delivering all her children by spontaneous vaginal birth). CONCLUSION: Forceps deliveries and perineal lacerations, but not episiotomies, were associated with pelvic floor disorders 5–10 years after a first delivery. LEVEL OF EVIDENCE: II

Obstetrical anal sphincter laceration and anal incontinence 5-10 years after childbirth

OBJECTIVE The purpose of this study was to investigate the long-term impact of anal sphincter laceration on anal incontinence. STUDY DESIGN Five to 10 years after first delivery, anal incontinence and other bowel symptoms were measured with the Epidemiology of Prolapse and Incontinence Questionnaire and the short form of the Colorectal-Anal Impact Questionnaire. Obstetric exposures were assessed with review of hospital records. Symptoms and quality-of-life impact were compared among 90 women with at least 1 anal sphincter laceration, 320 women who delivered vaginally without sphincter laceration, and 527 women who delivered by cesarean delivery. RESULTS Women who sustained an anal sphincter laceration were most likely to report anal incontinence (odds ratio, 2.32; 95% confidence interval, 1.27-4.26) and reported the greatest negative impact on quality of life. Anal incontinence and quality-of-life scores were similar between women who delivered by cesarean section and those who delivered vaginally without sphincter laceration. CONCLUSION Anal sphincter laceration is associated with anal incontinence 5-10 years after delivery.

Abdominal sacrocolpopexy: anatomic outcomes and complications with Pelvicol, autologous and synthetic graft materials

OBJECTIVE The purpose of this study was to compare anatomic outcomes and graft-related complications (GRCs) for abdominal sacrocolpopexy (ASC) with Pelvicol (CR BARD, Murray Hill, NJ), autologous fascia, and synthetic grafts. STUDY DESIGN This is a retrospective cohort study of ASC from 2001-2005. We reviewed anatomic outcomes and GRCs. Apical failure was defined as >stage 0. RESULTS Of 259 ASC procedures, Pelvicol was used in 102 procedures (39%); synthetic mesh in 134 procedures (52%), and autologous fascia in 23 procedures (9%). Mean postoperative follow up was 1.1 years. Apical failure by graft group were Pelvicol 10 (11%), synthetics 1 (1%), and autologous 1 (7%; P = .011). All 7 reoperations for apical prolapse were in the Pelvicol group. GRCs occurred in 16% of the cases, with a higher proportion of erosions in the Pelvicol group (11% vs 3% and 4%; P = .045). Reoperations as a result of GRC were similar between groups. CONCLUSION ASC is more likely to fail with Pelvicol than with synthetic or autologous grafts. The use of Pelvicol did not reduce graft-related complications in this population.

Mothers' Satisfaction with Planned Vaginal and Planned Cesarean Birth

We sought to describe maternal satisfaction with childbirth among women planning either cesarean or vaginal birth. We enrolled primiparous women planning cesarean birth and a comparison group planning vaginal birth. After delivery, the maternal subjective experience was assessed with a visual analogue satisfaction scale and the Salmon questionnaire, with scale scores for these aspects of the maternal experience of birth: fulfillment, distress, and difficulty. The sample included 160 women planning vaginal birth and 44 women planning cesarean. Eight weeks postpartum, women planning cesarean reported higher satisfaction ratings ( P = 0.023), higher scores for fulfillment ( P = 0.017), lower scores for distress ( P = 0.010), and lower scores for difficulty ( P < 0.001). The least favorable scores were associated with unplanned cesarean ( N = 48). Women planning cesarean reported a more favorable birth experience than women planning vaginal birth, due in part to low satisfaction associated with unplanned cesarean. Maternal satisfaction with childbirth may be improved by efforts to reduce unplanned cesarean, but also by support for maternal-choice cesarean.

Vaginal and laparoscopic mesh hysteropexy for uterovaginal prolapse: a parallel cohort study

BACKGROUND: There is growing interest in uterine conservation at the time of surgery for uterovaginal prolapse, but limited data compare different types of hysteropexy. OBJECTIVE: We sought to compare 1‐year efficacy and safety of laparoscopic sacral hysteropexy and vaginal mesh hysteropexy. STUDY DESIGN: This multicenter, prospective parallel cohort study compared laparoscopic sacral hysteropexy to vaginal mesh hysteropexy at 8 institutions. We included women ages 35–80 years who desired uterine conservation, were done with childbearing, and were undergoing 1 of the above procedures for stage 2–4 symptomatic anterior/apical uterovaginal prolapse (anterior descent at or beyond the hymen [Aa or Ba ≥ 0] and apical descent at or below the midvagina [C ≥ –TVL/2]). We excluded women with cervical elongation, prior mesh prolapse repair, cervical dysplasia, chronic pelvic pain, uterine abnormalities, and abnormal bleeding. Cure was defined as no prolapse beyond the hymen and cervix above midvagina (anatomic), no vaginal bulge sensation (symptomatic), and no reoperations. Pelvic Organ Prolapse Quantification examination and validated questionnaires were collected at baseline and 12 months including the Pelvic Floor Distress Inventory Short Form, Female Sexual Function Index, and Patient Global Impression of Improvement. In all, 72 subjects/group were required to detect 94% vs 75% cure (80% power, 15% dropout). Intention‐to‐treat analysis was used with logistic regression adjusting for baseline differences. RESULTS: We performed 74 laparoscopic sacral hysteropexy and 76 vaginal mesh hysteropexy procedures from July 2011 through May 2014. Laparoscopic patients were younger (P < .001), had lower parity (P = .006), were more likely premenopausal (P = .008), and had more severe prolapse (P = .02). Laparoscopic procedure (174 vs 64 minutes, P < .0001) and total operating time (239 vs 112 minutes, P < .0001) were longer. There were no differences in blood loss, complications, and hospital stay. One‐year outcomes for the available 83% laparoscopic and 80% vaginal hysteropexy patients revealed no differences in anatomic (77% vs 80%; adjusted odds ratio, 0.48; P = .20), symptomatic (90% vs 95%; adjusted odds ratio, 0.40; P = .22), or composite (72% vs 74%; adjusted odds ratio, 0.58; P = .27) cure. Mesh exposures occurred in 2.7% laparoscopic vs 6.6% vaginal hysteropexy (P = .44). A total of 95% of each group were very much better or much better. Pelvic floor symptom and sexual function scores improved for both groups with no difference between groups. CONCLUSION: Laparoscopic sacral hysteropexy and vaginal mesh hysteropexy had similar 1‐year cure rates and high satisfaction.

Pelvic Muscle Strength After Childbirth

OBJECTIVE: The objective was to estimate the effect of vaginal childbirth and other obstetric exposures on pelvic muscle strength 6–11 years after delivery and to investigate the relationship between pelvic muscle strength and pelvic floor disorders. METHODS: Among 666 parous women, pelvic muscle strength was measured with a perineometer 6–11 years after delivery. Obstetric exposures were classified by review of hospital records. Pelvic floor outcomes, including stress incontinence, overactive bladder, anal incontinence, and prolapse symptoms, were assessed with a validated questionnaire. Pelvic organ support was assessed using the Pelvic Organ Prolapse Quantification system. Kruskal-Wallis tests were used to estimate the univariable associations of obstetric exposures and pelvic floor outcomes with peak muscle strength. Stepwise multivariable linear regression models were used to estimate the association between obstetric exposures and muscle strength. RESULTS: In comparison with women who delivered all of their children by cesarean, peak muscle strength and duration of contraction were reduced among women with a history of vaginal delivery (39 compared with 29 cm H2O, P<.001). Pelvic muscle strength was further reduced after history of forceps delivery (17 cm H2O, P<.001). After vaginal delivery, reduced pelvic muscle strength was associated with symptoms of anal incontinence (P=.028) and pelvic organ prolapse on examination (P=.025); these associations were not observed among those who had delivered exclusively by cesarean. CONCLUSION: Pelvic muscle strength almost a decade after childbirth is affected by vaginal delivery and by forceps delivery. Although statistically significant, some of the differences observed were small in magnitude. LEVEL OF EVIDENCE: II

Comparison of levator ani muscle avulsion injury after forceps-assisted and vacuum-assisted vaginal childbirth.

OBJECTIVE: Using three-dimensional transperineal ultrasonography, we compared the prevalence of levator ani muscle injury after forceps with vacuum-assisted vaginal delivery. METHODS: This was a retrospective cohort study. Women who experienced at least one forceps delivery (across all deliveries) were compared with women who had at least one vacuum birth. On average, participants were 10 years from the index delivery. Three-dimensional transperineal ultrasound volumes were captured as cine loops at rest with Valsalva and with pelvic floor muscle contraction. The primary outcome was levator ani muscle avulsion. Secondary outcomes included hiatal diameter and area. Prevalence of pelvic floor disorders was also compared between the two delivery groups. RESULTS: Among 45 participants in the forceps group and 28 participants in the vacuum group, there were no differences between groups in maternal age at first delivery, parity, body mass index, birth weight, episiotomy, or duration of second stage. History of anal sphincter laceration was more common in the forceps group. The prevalence of levator ani muscle avulsion was significantly higher after forceps compared with vacuum delivery (22/45 [49%] compared with 5/28 [18%], P=.012, prevalence ratio 2.74, 95% confidence interval [CI] 1.17–6.40, odds ratio 4.40 [95% CI 1.42–13.62]). Controlling for delivery type, levator ani muscle avulsion was associated with symptoms of prolapse (P=.036), although objective evidence of prolapse was not significantly different between groups (P=.20). CONCLUSION: Ten years after delivery, the prevalence of levator avulsion is almost tripled after forceps compared with vacuum-assisted vaginal delivery. LEVEL OF EVIDENCE: II

Longitudinal changes in overactive bladder and stress incontinence among parous women

To describe longitudinal changes in symptoms of overactive bladder (OAB) and stress urinary incontinence (SUI) among parous women.

Scheduled cesarean delivery: maternal and neonatal risks in primiparous women in a community hospital setting.

We compared the short-term maternal and neonatal outcomes of women who deliver by cesarean without labor compared with women who deliver by cesarean after labor or by vaginal birth. This was a retrospective cohort study of women delivering a first baby from 1998 to 2002. Hospital discharge diagnostic coding identified unlabored cesarean deliveries (UCDs), labored cesarean deliveries (LCDs), and vaginal births (VBs). Medical records were abstracted and mode of delivery confirmed. The three outcomes of interest were maternal bleeding complications, maternal febrile morbidity, and neonatal respiratory complications. Using logistic regression for each outcome, we investigated whether mode of delivery was associated with the outcome, independent of other factors. The study groups included 513 UCDs, 261 LCDs, and 251 VBs. Compared with the UCD group, the adjusted odds of bleeding complications was higher in the LCD comparison group (odds ratio [OR] 2.3; 95% confidence interval [CI] 1.21, 4.53) and the VB comparison group (OR 1.96; 95% CI 0.95, 4.02). The incidence of febrile morbidity was similar for both cesarean groups but lower in the VB group. Both comparison groups had lower odds of neonatal complications than the UCD group (OR for LCD comparison group 0.52; 95% CI 0.27, 0.95 and OR for VB comparison group 0.26; 95% CI 0.098, 0.59). Scheduled cesarean is associated with increased odds of neonatal respiratory complications but decreased odds of maternal bleeding complications.