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Introduction and Hypothesis: Obstetric anal sphincter injury (OASI) is a major complication associated with vacuum-assisted vaginal delivery (VAVD). The aim of this study was to evaluate risk factors related to vacuum extraction that are associated with OASI. Methods: This was a case–control study performed at a tertiary university teaching hospital. Included were patients aged 18–45 years who had a singleton pregnancy resulting in a live, term, VAVD. The study group consisted of women diagnosed with OASI following vacuum extraction. The control group included women following VAVD without OASI. Matching at a ratio of 1:2 was performed. Groups were compared regarding demographic, obstetric. and labor-related parameters, specifically focusing on variables related to the vacuum procedure itself. Results: One hundred and ten patients within the study group and 212 within the control group were included in the final analysis. Patients in the OASI group were more likely to undergo induction of labor, use of oxytocin during labor, increased second stage of labor, higher likelihood of the operator being a resident, increased number of pulls, procedure lasting under 10 min, occipito-posterior head position at vacuum initiation, episiotomy, increased neonatal head circumference, and birthweight. Multivariate logistic regression analysis revealed that increased week of gestation (OR 1.67, 95% CI 1.25–2.22, p < 0.001), unsupervised resident performing the procedure (OR 4.63, 95% CI 2.17–9.90), p < 0.001), indication of VAVD being fetal distress (OR 2.72, 95% CI 1.04–7.10, p = 0.041), and length of procedure under 10 min (OR 4.75, 95% CI 1.53–14.68, p = 0.007) were associated with OASI. Increased maternal age was associated with lower risk of OASI (OR 0.9, 95% CI 0.84–0.98, p = 0.012). Conclusions: When performing VAVD, increased week of gestation, unsupervised resident performing the procedure, fetal distress as vacuum indication, and vacuum procedure under 10 min were associated with OASI. In contrast, increased maternal age was shown to be a protective factor. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: To date there has been scant knowledge on the natural recovery of the pelvic floor muscles (PFMs) after childbirth. The aims of the present study were to investigate whether PFM variables at 6 and 12 months postpartum had returned to mid-pregnancy levels and assess risk factors for reduced recovery at 12 months postpartum. Methods: This was a prospective cohort study following 235 nulliparous pregnant women from mid-pregnancy to 12 months postpartum. Vaginal resting pressure (VRP), PFM strength and endurance were assessed by manometry at 22 weeks, 6 and 12 months postpartum. Multiple linear regression was used to address factors influencing PFM variables beyond birth mode. Results: Cesarean section was protective for change in PFM variables. From mid-pregnancy to 12 months postpartum there was a 20% reduction in VRP (p<0.001) and a 7.5 % reduction in PFM strength (p=0.007), and an increase of 9% in PFM endurance (p=0.002) in the normal vaginal birth. The instrumental vaginal group had a decline in VRP of 21% (p<0.001) and PFM strength of 15% (p=0.011), but no significant change in PFM endurance. Higher BMI at 12 months postpartum, longer second stage of labor, and major tears of the levator ani muscle had a negative influence on the PFM recovery beyond delivery mode. Conclusions: At 12 months postpartum following vaginal delivery, the PFMs are not fully recovered compared with mid-pregnancy values. More follow-up physical therapy may be warranted in the postpartum period, especially for women with complicated vaginal births and higher BMI. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Slow progress of labour is a risk for operative delivery. Smaller levator hiatal dimensions are possible risk factors for slow progress and operative delivery. Our aim was to explore associations between hiatal dimensions antenatally, duration of second stage of labour and mode of delivery. Methods: Prospective cohort study of 65 nullipara examined at 20 weeks gestation and 6 months postpartum. Levator hiatal anteroposterior diameter and area were measured using 2D/3D transperineal ultrasound and compared between women with normal vaginal delivery and operative delivery (vacuum or caesarean) using t-test and with Spearman's rank to explore correlations with duration of second stage. ROC analysis established a cut-off for high risk of operative delivery. Results: Two-dimensional anteroposterior diameter and 3D hiatal area at rest were smaller in women with operative delivery than with normal delivery, 5.0 cm vs. 5.7 cm, p = 0.007 and 18.5 cm2 vs. 14.9 cm2, p < 0.001. From the ROC curve for 2D anteroposterior diameter, a cut-off of 5.6 cm, (sensitivity = 0.94, specificity = 0.63) and for 3D hiatal area a cut-off of 17.6 cm2 (sensitivity = 0.94, specificity = 0.65) predicted operative delivery. We found inverse correlations between second stage of labour and anteroposterior diameter at rest, r = −0.330, contraction, r = −0.365, area at rest, r = −0.324, and contraction, r = −0.521, all p < 0.05. Conclusions: Smaller hiatal dimensions at 20 weeks gestation were associated with longer second stage of labour and increased risk of operative delivery in nullipara. A 2D anteroposterior hiatal diameter < 5.6 cm and 3D hiatal area < 17.6 cm2 at rest imply increased risk of operative delivery. [ABSTRACT FROM AUTHOR]

Introduction and Hypothesis: Postpartum urinary retention is one of the most common complications in women during the immediate postpartum period. The objective was to systematically assess risk factors for postpartum urinary retention after vaginal delivery.Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we retrieved relevant studies from PubMed, Embase, Cochrane Library, Web of Science Core Collection, China National Knowledge Internet, Wangfang Database, and Chinese Biomedical Database for observational studies investigating the risk factors for postpartum urinary retention from inception to 11 November 2022. The Newcastle–Ottawa Scale and Joanna Briggs Institute's tool were used to assess the risk of bias. We conducted a meta-analysis using RevMan 5.3.In total, 3,074 articles were screened and data from 27 studies were used in the meta-analysis. Sixteen risk factors were identified, namely, labor augmentation (OR = 1.72, 95% CI = 1.17–2.51), primiparity (OR = 2.36, 95% CI = 1.64–3.38), manual fundal pressure (OR = 2.84, 95% CI = 1.00–8.11), perineal hematoma (OR = 7.28, 95% CI = 1.62–32.72), vulvar edema (OR = 7.99, 95% CI = 5.50–11.63), the total duration of labor (MD = 90.10, 95% CI = 49.11–131.08), the duration of the first stage of labor (MD = 33.97, 95% CI = 10.28–57.65), the duration of the second stage of labor (MD = 14.92, 95% CI = 11.79–18.05), the duration of the second stage of labor > 60 min (OR = 3.18, 95% CI = 1.32–7.67), mediolateral episiotomy (OR = 3.65, 95% CI = 1.70–7.83), severe perineal tear (OR = 3.21, 95% CI = 1.84–5.61), epidural analgesia (OR = 3.23, 95% CI = 1.50–6.96), forceps delivery (OR = 4.95, 95% CI = 2.88–8.51), vacuum delivery (OR = 2.44, 95% CI = 1.30–4.58), neonatal birth weight > 4,000 g (OR = 3.61, 95% CI = 1.96–6.65), and neonatal birth weight > 3,500 g (OR = 1.89, 95% CI = 1.12–3.19).Our results demonstrated that labor augmentation, primiparity, manual fundal pressure, perineal hematoma, vulvar edema, the total duration of labor, the duration of the first stage of labor, the duration of the second stage of labor, the duration of the second stage of labor > 60 min, mediolateral episiotomy, severe perineal tear, epidural analgesia, forceps delivery, vacuum delivery, and neonatal birth weight > 4,000 g and > 3,500 g were risk factors for postpartum urinary retention in women with vaginal delivery. The specific ranges of the first and the second stages of labor causing postpartum urinary retention need to be clarified.Methods: Postpartum urinary retention is one of the most common complications in women during the immediate postpartum period. The objective was to systematically assess risk factors for postpartum urinary retention after vaginal delivery.Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we retrieved relevant studies from PubMed, Embase, Cochrane Library, Web of Science Core Collection, China National Knowledge Internet, Wangfang Database, and Chinese Biomedical Database for observational studies investigating the risk factors for postpartum urinary retention from inception to 11 November 2022. The Newcastle–Ottawa Scale and Joanna Briggs Institute's tool were used to assess the risk of bias. We conducted a meta-analysis using RevMan 5.3.In total, 3,074 articles were screened and data from 27 studies were used in the meta-analysis. Sixteen risk factors were identified, namely, labor augmentation (OR = 1.72, 95% CI = 1.17–2.51), primiparity (OR = 2.36, 95% CI = 1.64–3.38), manual fundal pressure (OR = 2.84, 95% CI = 1.00–8.11), perineal hematoma (OR = 7.28, 95% CI = 1.62–32.72), vulvar edema (OR = 7.99, 95% CI = 5.50–11.63), the total duration of labor (MD = 90.10, 95% CI = 49.11–131.08), the duration of the first stage of labor (MD = 33.97, 95% CI = 10.28–57.65), the duration of the second stage of labor (MD = 14.92, 95% CI = 11.79–18.05), the duration of the second stage of labor > 60 min (OR = 3.18, 95% CI = 1.32–7.67), mediolateral episiotomy (OR = 3.65, 95% CI = 1.70–7.83), severe perineal tear (OR = 3.21, 95% CI = 1.84–5.61), epidural analgesia (OR = 3.23, 95% CI = 1.50–6.96), forceps delivery (OR = 4.95, 95% CI = 2.88–8.51), vacuum delivery (OR = 2.44, 95% CI = 1.30–4.58), neonatal birth weight > 4,000 g (OR = 3.61, 95% CI = 1.96–6.65), and neonatal birth weight > 3,500 g (OR = 1.89, 95% CI = 1.12–3.19).Our results demonstrated that labor augmentation, primiparity, manual fundal pressure, perineal hematoma, vulvar edema, the total duration of labor, the duration of the first stage of labor, the duration of the second stage of labor, the duration of the second stage of labor > 60 min, mediolateral episiotomy, severe perineal tear, epidural analgesia, forceps delivery, vacuum delivery, and neonatal birth weight > 4,000 g and > 3,500 g were risk factors for postpartum urinary retention in women with vaginal delivery. The specific ranges of the first and the second stages of labor causing postpartum urinary retention need to be clarified.Results: Postpartum urinary retention is one of the most common complications in women during the immediate postpartum period. The objective was to systematically assess risk factors for postpartum urinary retention after vaginal delivery.Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we retrieved relevant studies from PubMed, Embase, Cochrane Library, Web of Science Core Collection, China National Knowledge Internet, Wangfang Database, and Chinese Biomedical Database for observational studies investigating the risk factors for postpartum urinary retention from inception to 11 November 2022. The Newcastle–Ottawa Scale and Joanna Briggs Institute's tool were used to assess the risk of bias. We conducted a meta-analysis using RevMan 5.3.In total, 3,074 articles were screened and data from 27 studies were used in the meta-analysis. Sixteen risk factors were identified, namely, labor augmentation (OR = 1.72, 95% CI = 1.17–2.51), primiparity (OR = 2.36, 95% CI = 1.64–3.38), manual fundal pressure (OR = 2.84, 95% CI = 1.00–8.11), perineal hematoma (OR = 7.28, 95% CI = 1.62–32.72), vulvar edema (OR = 7.99, 95% CI = 5.50–11.63), the total duration of labor (MD = 90.10, 95% CI = 49.11–131.08), the duration of the first stage of labor (MD = 33.97, 95% CI = 10.28–57.65), the duration of the second stage of labor (MD = 14.92, 95% CI = 11.79–18.05), the duration of the second stage of labor > 60 min (OR = 3.18, 95% CI = 1.32–7.67), mediolateral episiotomy (OR = 3.65, 95% CI = 1.70–7.83), severe perineal tear (OR = 3.21, 95% CI = 1.84–5.61), epidural analgesia (OR = 3.23, 95% CI = 1.50–6.96), forceps delivery (OR = 4.95, 95% CI = 2.88–8.51), vacuum delivery (OR = 2.44, 95% CI = 1.30–4.58), neonatal birth weight > 4,000 g (OR = 3.61, 95% CI = 1.96–6.65), and neonatal birth weight > 3,500 g (OR = 1.89, 95% CI = 1.12–3.19).Our results demonstrated that labor augmentation, primiparity, manual fundal pressure, perineal hematoma, vulvar edema, the total duration of labor, the duration of the first stage of labor, the duration of the second stage of labor, the duration of the second stage of labor > 60 min, mediolateral episiotomy, severe perineal tear, epidural analgesia, forceps delivery, vacuum delivery, and neonatal birth weight > 4,000 g and > 3,500 g were risk factors for postpartum urinary retention in women with vaginal delivery. The specific ranges of the first and the second stages of labor causing postpartum urinary retention need to be clarified.Conclusions: Postpartum urinary retention is one of the most common complications in women during the immediate postpartum period. The objective was to systematically assess risk factors for postpartum urinary retention after vaginal delivery.Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we retrieved relevant studies from PubMed, Embase, Cochrane Library, Web of Science Core Collection, China National Knowledge Internet, Wangfang Database, and Chinese Biomedical Database for observational studies investigating the risk factors for postpartum urinary retention from inception to 11 November 2022. The Newcastle–Ottawa Scale and Joanna Briggs Institute's tool were used to assess the risk of bias. We conducted a meta-analysis using RevMan 5.3.In total, 3,074 articles were screened and data from 27 studies were used in the meta-analysis. Sixteen risk factors were identified, namely, labor augmentation (OR = 1.72, 95% CI = 1.17–2.51), primiparity (OR = 2.36, 95% CI = 1.64–3.38), manual fundal pressure (OR = 2.84, 95% CI = 1.00–8.11), perineal hematoma (OR = 7.28, 95% CI = 1.62–32.72), vulvar edema (OR = 7.99, 95% CI = 5.50–11.63), the total duration of labor (MD = 90.10, 95% CI = 49.11–131.08), the duration of the first stage of labor (MD = 33.97, 95% CI = 10.28–57.65), the duration of the second stage of labor (MD = 14.92, 95% CI = 11.79–18.05), the duration of the second stage of labor > 60 min (OR = 3.18, 95% CI = 1.32–7.67), mediolateral episiotomy (OR = 3.65, 95% CI = 1.70–7.83), severe perineal tear (OR = 3.21, 95% CI = 1.84–5.61), epidural analgesia (OR = 3.23, 95% CI = 1.50–6.96), forceps delivery (OR = 4.95, 95% CI = 2.88–8.51), vacuum delivery (OR = 2.44, 95% CI = 1.30–4.58), neonatal birth weight > 4,000 g (OR = 3.61, 95% CI = 1.96–6.65), and neonatal birth weight > 3,500 g (OR = 1.89, 95% CI = 1.12–3.19).Our results demonstrated that labor augmentation, primiparity, manual fundal pressure, perineal hematoma, vulvar edema, the total duration of labor, the duration of the first stage of labor, the duration of the second stage of labor, the duration of the second stage of labor > 60 min, mediolateral episiotomy, severe perineal tear, epidural analgesia, forceps delivery, vacuum delivery, and neonatal birth weight > 4,000 g and > 3,500 g were risk factors for postpartum urinary retention in women with vaginal delivery. The specific ranges of the first and the second stages of labor causing postpartum urinary retention need to be clarified. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: To evaluate the effect of the second stage of labor (SSL) lasting > 2 h on pelvic floor function. Methods: This single-center prospective cohort study included primiparous women with SSL > 2 h treated at Tongji Hospital between January 2018 and December 2019 (case group). A matched group of women with similar newborn weight and SSL < 2 h were recruited simultaneously (control group). Stress urinary incontinence (SUI) and pelvic floor muscle (PFM) characteristics were measured at 6 weeks, 6 months, and finally 1 year postpartum. Results: A total of 63 pairs of primiparous women completed 1-year follow-up. The incidence of SUI in the case group was significantly higher than that in the control group at 6 weeks postpartum (P = 0.020); however, the differences were not significant at 1 year postpartum (P=1.00). PFM endurance was significantly lower in the case group at 6 weeks (P = 0.000), 6 months (P = 0.000), and 1 year (P = 0.011) after childbirth. There was no difference in PFM strength between the two groups. The maximal voluntary contraction (MVC) of PFM was significantly lower in the case group at 6 weeks postpartum (P = 0.007), but the differences were not significant at 1 year postpartum (P = 0.197). PFM endurance and MVC were higher at 1 year than at 6 weeks postpartum in both groups. Conclusions: The SSL > 2 h increased the incidence of SUI at 6 weeks postpartum and decreased PFM endurance for 1 year. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Directed pushing while using the Valsalva maneuver is shown to lead to bladder neck descent, especially in women with urinary incontinence (UI). There is insufficient evidence about the benefits or adverse effects between the pushing technique during the second stage of labor and urinary incontinence postpartum. The objective of this study was to evaluate the effects of the pushing technique for women during labor on postpartum UI and birth outcomes. Methods: Scientific databases were searched for studies relating to postpartum urinary incontinence and birth outcomes when the pushing technique was used from 1986 until 2020. RCTs that assessed healthy primiparas who used the pushing technique in the second stage of labor were included. In accordance with Cochrane Handbook guidelines, risk of bias was assessed and meta-analyzed. Certainty of evidence was assessed using the GRADE approach. Results: Seventeen RCTs (4606 primiparas) were included. The change in UI scores from baseline to postpartum was significantly lower as a result of spontaneous pushing (two studies; 867 primiparas; standardized mean difference: SMD –0.18, 95% CI –0.31 to –0.04). Although women were in the recumbent position during the second stage, directed pushing group showed a significantly shorter labor by 21.39 min compared with the spontaneous pushing group: there was no significant difference in the duration of the second stage of labor between groups. Conclusions: Primiparas who were in the upright position and who experienced spontaneous pushing during the second stage of labor could reduce their UI score from baseline to postpartum. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Obstetrical anal sphincter injury (OASIS) is a common consequence of vaginal delivery in nulliparas and carries the risk of short- and long-term morbidity. The objective of this study was to estimate the association between the duration of the second stage of labour and OASIS risk. Methods: A population-based, retrospective cohort of nulliparas delivering singleton, vertex, non-anomalous fetuses at term in Nova Scotia, Canada, from 2005 to 2019, were identified using the Nova Scotia Atlee Perinatal Database. Poisson regression models were used to estimate risk ratios (RR) with robust 95% confidence intervals (CI) adjusting for confounding variables to investigate the association between the length of the second stage and OASIS in the entire cohort and in operative vaginal deliveries. Results: Of 36,662 participants, 7.6% sustained an OASIS (6.8% third-degree, 0.8% fourth-degree tear). The proportion of participants who sustained an OASIS increased over the study period. For each 30-min increase in the length of second stage, the OASIS risk increased by 11% (RR 1.11, 95% CI 1.10–1.12). When stratified by mode of delivery, second stage length ≥ 90 min was associated with an increased OASIS risk in spontaneous (RR 1.35, 95% CI 1.15–1.58) and vacuum-assisted vaginal deliveries (RR 1.42, 95% CI 1.11–1.81). In forceps-assisted vaginal deliveries, OASIS risk was increased, with shorter and longer durations of the second stage. Conclusion: Increasing length of the second stage of labour was associated with increasing risk of OASIS overall, but the association was heterogeneous between modes of delivery. Length of the second stage should be considered in counseling about OASIS risk. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: This study was aimed at exploring the mediating role of the prolonged second stage of labor (PSSL) in the association between delivery mode and urinary incontinence (UI) among postpartum women in Shandong, China. Methods: A cross-sectional study involving postnatal women from the Women's Pelvic Floor Functional Health Center in Shandong, China, was conducted. An electronic questionnaire was used to collect the data between June 2020 and February 2021. UI was assessed using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). Logistic regression and multiple linear regression were employed to explore the association among delivery mode, PSSL, and UI, and the mediating role of PSSL. Results: Among the total of 5,586 postpartum women included in this study, the prevalence of UI was 13.3%. Among the 742 patients with UI, the prevalence of stress urinary incontinence (78.3%) was greater than urge urinary incontinence (8.6%), mixed urinary incontinence (9.3%), and others (3.8%). After adjusting for controlling variables, delivery mode was found to be significantly associated with PSSL, whereby women with vaginal delivery were more likely to be in PSSL, and women with PSSL had a higher probability of suffering from UI. PSSL played a partial mediating effect in delivery mode and UI. Conclusions: This study provided evidence that the effect of delivery mode on UI was partially mediated by PSSL among postpartum women in Shandong, China. Strategies to prevent PSSL should be actively adopted to reduce the risk of UI in women. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Persistent postpartum pelvic pain affects one in six women, and its source is often unexplained in the absence of obvious clinical findings. Musculoskeletal injuries during childbirth are common and can be detected using MRI or US; however, pelvic imaging is not standard of care in evaluating women with persistent pain. We hypothesize that clinical symptoms in women with unexplained persistent postpartum pelvic pain will correlate with musculoskeletal abnormalities identified on MRI in > 50% of cases. Methods: Retrospective cohort study of women with persistent postpartum pelvic pain who underwent a pelvic MRI for this indication. Chart review was performed. MRI findings were classified as major (bone fracture, levator ani avulsion) or minor (edema, inflammation or partial levator ani defect). Descriptive statistics were used to describe the study population. Results: Of the 252 women seen for postpartum pelvic pain, 18 patients met our study criteria. Half of women were primiparous (55.6%, n = 10). Operative delivery occurred in 27.8% (n = 5), 22.2% (n = 4) had anal sphincter lacerations, and 38.9% (n = 7) had prolonged second stage of labor. Median time from delivery to MRI was 4.5 ± 5.13 (IQR) months. Musculoskeletal abnormalities were found in 94.4% (n = 17) of cases; 38.8% (n = 7) were major and 55.6% (n = 10) were minor abnormalities. All findings correlated with presenting symptoms. Conclusion: Of women with persistent postpartum pelvic pain, 94.4% had musculoskeletal abnormalities supporting their clinical symptoms. Pelvic floor imaging should be considered in women with unexplained persistent postpartum pelvic pain to accurately manage the source of their pain. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Catheterization type among women laboring with epidural analgesia who develop bladder retention has been reported to affect labor duration and mode of delivery. We aimed to compare the effect of continuous bladder catheterization (CC) with that of intermittent bladder catheterization (IC) on the duration of the second stage of labor.Methods: In a randomized trial, term nulliparous women with singleton gestation who requested epidural analgesia and were unable to void spontaneously were eligible and randomized to either CC or IC. Epidural analgesia was maintained with patient control until delivery. The primary outcome was duration of the second stage of labor. Secondary outcomes were mode of delivery, and incidences of postpartum hemorrhage, bladder retention, and infection. It was assumed that, compared with IC, CC might better prevent bladder distention, which is thought to delay fetal descent. A sample size of 90 women in each group was calculated to be adequate to detect a reduction of 30 min in the duration of the second stage of labor among the CC group.Results: Between July 2014 and May 2015, a total of 184 women were randomized and included in the analysis; 90 and 94 women in the CC and IC groups respectively. Demographic and obstetric characteristics were similar. Duration of the second stage was 121.0 ± 89.4 and 131.9 ± 87.5 min in the CC and IC groups respectively (p = 0.29). The two groups did not differ significantly with regard to delivery mode, third-stage duration, and incidences of postpartum hemorrhage, bladder retention, and urinary tract infection.Conclusion: Duration of the second stage of labor is not influenced by bladder catheterization type in nulliparous women receiving an epidural. [ABSTRACT FROM AUTHOR]

10.1111/1471-0528.13223 5 Van Gruting MA, van Delft KWM, Sultan AH, Thakar R. The natural history of levator ani muscle avulsion 4 years following childbirth. Also, the lack of multiparous women, previous delivery data, pre-labor pelvic floor function, and levator avulsion rates in both groups were other limitations of this study. Early findings in the levator ani muscle (LAM) may heal afterward in the natural history of avulsion [[3]]. [Extracted from the article]

1 (a) The reference image from Takmaz's article assessing levator ani avulsion. 2 Youssef A, Salsi G, Cataneo I, Pacella G, Azzarone C, Paganotto MC, Krsmanovic J, Montaguti E, Cariello L, Bellussi F, Rizzo N, Pilu G. Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion. [Extracted from the article]

As they mentioned, similar to their pioneering study we found a higher risk of levator ani muscle (LAM) defect immediately after vaginal delivery [[2]]. In a review of the literature on the natural history of LAM avulsion, van Delft et al. reported that 62% of major LAM avulsions which were diagnosed at 3 months postpartum were no longer evident (healed) at 1-year follow-up [[4]]. 2 Youssef A, Salsi G, Cataneo I, Pacella G, Azzarone C, Paganotto MC, Krsmanovic J, Montaguti E, Cariello L, Bellussi F, Rizzo N, Pilu G. Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion. [Extracted from the article]

We did not find significant differences in terms of urinary or anal incontinence, genital prolapse, and pelvic floor strength, whereas mediolateral episiotomies, dyspareunia, and perineal pain were significantly higher in the Kristeller group. Apparently, our results seem to contrast with those obtained by Takmaz et al., although there is a substantial difference: we made a clinical and instrumental evaluation of the pelvic floor 3 months after delivery, whereas Takmaz et al. used only ultrasonography within 2 days of delivery. Dear Editor, We would like to comment on the article written by Takmaz and colleagues that evaluated the relationship between uterine fundal pressure during delivery and levator ani muscle defects in puerperium [[1]]. [Extracted from the article]