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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. [ABSTRACT FROM AUTHOR]

Importance: The Latina population is the largest growing ethnic group in the United States with high levels of health disparities in urinary incontinence (UI) treatment and complications rates, which may be due to disproportionately high barriers to UI care-seeking among Latinas., Objectives: The objectives of this study were to compare barriers to UI care-seeking among Latina, non-Latina Black, and non-Latina White patients by utilizing the Barriers to Incontinence Care Seeking Questionnaire (BICS-Q) total scores, and to compare specific barriers utilizing BICS-Q subscales., Study Design: In this cross-sectional study, patients accessing primary care were recruited to complete the BICS-Q, International Consultation on Incontinence Questionnaire-Short Form, and Prolapse and Incontinence Knowledge Questionnaire-Urinary Incontinence. The BICS-Q total and subscale scores were compared among ethnic/racial groups., Results: A total of 298 patients were included in the study with 83 Black, 144 Latina, and 71 White participants per self-identified ethnicity/race. The total BICS-Q score was highest for Latina participants, followed by White and Black participants (11.2 vs 8.2 vs 4.9, respectively, P < 0.0001). Latina participants had significantly higher BICS-Q subscale scores compared with Black participants with no significant differences between Latina and White participants. After controlling for potential confounders, Latina ethnicity/race was still associated with a higher BICS-Q score when compared to Black ethnicity/race (P = 0.0077), and lower Prolapse and Incontinence Knowledge Questionnaire-Urinary Incontinence scores remained independently associated with higher BICS-Q scores (P = 0.0078)., Conclusions: In our study population, Latina patients and patients with lower UI knowledge experience higher barriers to UI care-seeking compared with Black patients and patients with higher UI knowledge. Addressing these barriers may increase care-seeking and improve health equity in the field., Competing Interests: The authors have declared they have no conflicts of interest. A.P. received the Gender and Racial Justice Scholars Award through the Johns Hopkins University Women’s Suffrage Centennial Commemoration Committee. The authors of this paper report no conflict of interest and no further disclosures., (Copyright © 2024 American Urogynecologic Society. All rights reserved.)

Objective: In cross-sectional studies, pelvic organ prolapse is strongly associated with genital hiatus (GH) size. The objective of this study was to estimate prolapse incidence by the size of the GH among parous women followed prospectively., Methods: Data were derived from a longitudinal study of pelvic floor disorders. Participants were followed annually for 2-9 years. Genital hiatus size and prolapse beyond the hymen were assessed with annual pelvic organ prolapse quantification examinations. Kaplan-Meier methods described prolapse-free survival as a function of GH size. Accounting for changes over time in GH size, lognormal models were used to estimate prolapse-free survival by GH size. This analysis was repeated separately for women who gave birth exclusively by cesarean versus those with at least one vaginal birth., Results: Among 1,492 participants, median age at enrollment was 38 years; 153 (10.3%) developed prolapse over 2-9 years. The cumulative probability of prolapse increased substantially as the size of the GH increased. Lognormal models predicted that the estimated median time to develop prolapse would be 33.4 years for women with a persistent GH of 3 cm; in contrast, the estimated median time to develop prolapse would be 5.8 years for a GH of 4.5 cm or greater. Considering separately women who gave birth by cesarean versus those with at least 1 vaginal birth, GH size drastically modified prolapse risk in both birth groups., Conclusions: Prolapse incidence is strongly associated with GH size, regardless of delivery mode. These findings suggest that a wider GH is an important predictor of future prolapse risk., Competing Interests: The author has declared that there are no conflicts of interest., (Copyright © 2020 American Urogynecologic Society. All rights reserved.)

Introduction and Hypothesis: To investigate the relationship between race and anal incontinence (AI). Our hypotheses were (a) AI symptoms are similar between white and black women and (b) asymptomatic black and white women are equally likely to develop AI over one year of prospective observation., Methods: Parous women enrolled in a longitudinal cohort study were assessed for AI symptoms annually using Epidemiology of Prolapse and Incontinence Questionnaire. An AI score > 0 indicated any bother from AI; a score > 22.8 indicated clinically significant AI. We compared the odds of AI scores >0 at the visit level between white vs black women with logistic regression models using generalized estimating equations. We also estimated the odds of new AI symptoms at time T + 1(one year later) among women free of AI symptoms at time T comparing white vs black women. In the latter analysis, we considered new AI symptoms to be represented by scores above 11.4. Covariates included in the adjusted models were: mode of delivery, obstetrical anal sphincter injuries, body mass index, age at the first delivery, and parity at enrollment., Results: Among 1256 participants, 189 (15.0%) were black. AI score = 0 was observed at 74.2% (= 5122/6902) person-visits. The adjusted odds ratio of AI score > 0 was 1.83 (95% CI 1.24, 2.70) for white vs black women. Across 4364 visit pairs with AI score = 0 at time T, 203 (4.7%) had AI score > 11.4 at visit T + 1 and white race significantly increased the odds of developing symptoms at time T + 1 (adjusted OR = 2.26, 95% CI 1.28, 3.98)., Conclusions: In an analysis that controlled for mode of delivery, obstetrical anal sphincter injuries, obesity, age at first delivery, and parity, white race was significantly associated with AI symptoms at any point in time as well as to the development of AI over one year of observation.

Background: Pelvic floor disorders (including urinary and anal incontinence and pelvic organ prolapse) are associated with childbirth. Injury to the pelvic floor muscles during vaginal childbirth, such as avulsion of the levator ani muscle, is associated with weaker pelvic floor muscle strength. As weak pelvic floor muscle strength may be a modifiable risk factor for the later development of pelvic floor disorders, it is important to understand how pelvic floor muscle strength affects the course of pelvic floor disorders over time., Objective: To investigate the association between pelvic floor muscle strength and the incidence of pelvic floor disorders, and to identify maternal and obstetrical characteristics that modify the association., Materials and Methods: This is a longitudinal study investigating pelvic floor disorders after childbirth. Participants were recruited 5-10 years after their first delivery and were assessed for pelvic floor disorders annually for up to 9 years. Stress incontinence, overactive bladder, and anal incontinence were assessed at each annual visit using the Epidemiology of Prolapse and Incontinence Questionnaire. Pelvic organ prolapse was assessed on physical examination, and was defined as descent of the vaginal walls or cervix beyond the hymen during forceful Valsalva. The primary exposure of interest was pelvic floor muscle strength, defined as the peak pressure during a voluntary pelvic muscle contraction (measured with a perineometer). The relationship between pelvic floor muscle strength and the cumulative incidence (time to event) of each pelvic floor disorder was evaluated using lognormal models, stratified by vaginal vs cesarean delivery. The relative hazard for each pelvic floor disorder (among those women free of the disorder at enrollment and thus more than 5-10 years from first delivery), was estimated using semiparametric proportional hazard models as a function of delivery mode, pelvic floor muscle strength, and other covariates., Results: Of 1143 participants, the median age was 40 (interquartile range, 36.6-43.7) years, and 73% were multiparous. On perineometry, women with at least 1 vaginal delivery were more likely to have a low peak pressure, defined as <20 cm H 2 O (243 of 588 women with at least 1 vaginal delivery vs 107 of 555 women who delivered all of their children by cesarean delivery, P < .001). Among women who had at least 1 vaginal delivery, a pelvic floor muscle strength of <20 cm H 2 O was associated with a shorter time to event for stress incontinence (time ratio, 0.67; 95% confidence interval, 0.50-0.90), overactive bladder (time ratio, 0.67; 95% confidence interval, 0.51-0.86), and pelvic organ prolapse (time ratio, 0.76; 95% confidence interval, 0.65-0.88). No such association was found among women who delivered all of their children by cesarean delivery. Among women with at least 1 vaginal delivery and considering only pelvic floor disorders that developed during study observation (5-10 years after the first delivery), and controlling for maternal characteristics (body mass index and genital hiatus), women who had a peak pressure of <20 cm H 2 O had hazard ratios (relative to ≥20 cm H 2 O) of 1.16 (95% confidence interval, 0.74-1.81) for stress incontinence, 1.27 (95% confidence interval, 0.78-2.05) for overactive bladder, and 1.43 (95% confidence interval, 0.99-2.07) for pelvic organ prolapse. Among women who delivered all of their children by cesarean delivery, there was no association between muscle strength and relative hazard of pelvic floor disorders when controlling for maternal characteristics., Conclusion: After vaginal delivery, but not cesarean delivery, the cumulative incidence of pelvic organ prolapse, stress incontinence, and overactive bladder is associated with pelvic muscle strength, but the associations attenuate when adjusting for genital hiatus and body mass index., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: Obstetric levator avulsion may be an important risk factor for prolapse. This study compares the size of the levator hiatus, the width of the genital hiatus, and pelvic muscle strength between vaginally parous women with or without levator avulsion, 5 to 15 years after delivery., Methods: Parous women were assessed for levator ani avulsion, using 3-dimensional transperineal ultrasound. Women with and without levator ani avulsion were compared with respect to levator hiatus areas (measured on ultrasound), genital hiatus (measured on examination), and pelvic muscle strength (measured with perineometry). Further analysis also considered the association of forceps-assisted birth., Results: At a median interval of 11 years from first delivery, levator avulsion was identified in 15% (66/453). A history of forceps-assisted delivery was strongly associated with levator avulsion (45% vs 8%; P < 0.001). Levator avulsion was also associated with a larger levator hiatus area (+7.3 cm; 95% confidence interval [CI], 4.1-10.4, with Valsalva), wider genital hiatus (+0.6 cm; 95% CI, 0.3-0.9, with Valsalva), and poorer muscle strength (-14.5 cm H2O; 95% CI, -20.4 to -8.7, peak pressure). Among those with levator avulsion, forceps-assisted birth was associated with a marginal increase in levator hiatus size but not genital hiatus size or muscle strength., Conclusions: Obstetric levator avulsion is associated with a larger levator hiatus, wider genital hiatus, and poorer pelvic muscle strength. Forceps-assisted birth is an important marker for levator avulsion but may not be an independent risk factor for the development of pelvic muscle weakness or changes in hiatus size in the absence of levator avulsion.

We aimed to explore relationships between changes in genital hiatus (GH) and development of pelvic organ prolapse using data from the Mothers' Outcomes After Delivery (MOAD) Study, a Baltimore, Maryland, cohort study of parous women who underwent annual assessments during 2008-2018. Prolapse was defined as any vaginal segment protrusion beyond the hymen or reported prolapse surgery. For each case, 5 controls (matched on birth type and interval from first delivery to study enrollment) were selected using incidence sampling methods. We used a mixed model whose fixed effects described the initial size and slope of the GH as a function of prolapse status (case vs. control) and with nested (women within matched sets) random effects. Among 1,198 women followed for 1.0-7.3 years, 153 (13%) developed prolapse; 754 controls were matched to those women, yielding 3,664 visits for analysis. GH was 20% larger among the cases at enrollment (3.16 cm in cases vs. 2.62 cm in controls; P < 0.001), and the mean rate of increase in the size of the GH was more than 3 times greater (0.56 cm per 5-year period vs. 0.15 cm per 5-year period in controls; P < 0.001). Thus, to identify women at highest risk for developing prolapse, health-care providers could evaluate not simply the size of the GH but also changes in the GH over time., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health.)

Background: Postpartum recovery from pelvic floor trauma associated with vaginal delivery may be impaired by the transient hypoestrogenic state associated with breastfeeding., Objective: The aim of our study was to examine the association between exclusive breastfeeding and pelvic floor disorders 1-2 decades after the first vaginal delivery. We hypothesize that compared with women who did not breastfeed following vaginal delivery, women who breastfeed would have a higher proportion of pelvic floor disorders s, and those women who practiced sustained exclusive/unsupplemented breastfeeding would have the highest proportion., Study Design: This is a secondary analysis of the Mothers' Outcomes After Delivery study, a prospective cohort study of pelvic floor disorders after childbirth. Participants were recruited 5-10 years after their first delivery and followed up annually for up to 9 years. This analysis focused on participants who experienced at least 1 vaginal delivery. Each participant completed a self-administered questionnaire regarding breastfeeding. Based on questionnaire responses, breastfeeding status was classified into 3 ordinal categories: unexposed (did not breastfeed or breastfed <1 week); limited exclusive breastfeeding (breastfed without supplementation for ≥1 week but <12 weeks); and sustained exclusive breastfeeding (unsupplemented breastfeeding ≥12 weeks). Our primary outcomes of interest were the proportions of stress urinary incontinence, anal incontinence, and pelvic organ prolapse. The outcomes of interest were defined using the Epidemiology of Prolapse and Incontinence Questionnaire and the Pelvic Organ Prolapse Quantification Examination at enrollment and annually for up to 9 years thereafter. Additionally, a subanalysis examined the relationship between breastfeeding and anal incontinence in an obstetric anal sphincter injury-specific population. Generalized estimating equations were utilized to determine the relationship between breastfeeding and the outcomes of interest., Results: Among 705 women, 189 (27%) were classified as unexposed, 145 (20%) were categorized as limited exclusive breastfeeding, and the remaining 371 women (53%) met our definition of sustained exclusive breastfeeding. Median follow-up was 5 years, contributing to a total of 3079 person years. The proportion of each pelvic floor disorder, based on 3079 person-years of follow-up was: stress urinary incontinence (27%), pelvic organ prolapse (20%), or anal incontinence (25%). Using generalized estimating equations adjusting for race, education, parity, and body mass index, sustained exclusive breastfeeding was not significantly associated with stress urinary incontinence (adjusted odds ratio, 0.82, 95% confidence interval, 0.55-1.23), pelvic organ prolapse (adjusted odds ratio, 0.78, 95% confidence interval, 0.49-1.26), and anal incontinence (adjusted odds ratio, 0.67, 95% confidence interval, 0.44-1.00). Regarding our obstetric anal sphincter injury subanalysis, 123 women within our cohort experienced obstetric anal sphincter injuries at delivery. Anal incontinence was reported in 32% of these women. However, there was no observed relationship between breastfeeding and the development of anal incontinence during study follow-up in this population., Conclusion: Breastfeeding after vaginal childbirth was not associated with the development of stress urinary incontinence, pelvic organ prolapse, or anal incontinence 1-2 decades after the first vaginal delivery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Obstetrical levator ani muscle avulsion is detected after 10%-30% of vaginal deliveries and is associated with pelvic organ prolapse later in life. However, the mechanism by which levator avulsion may contribute to prolapse is unknown., Objectives: This study investigated the extent by which size of the levator hiatus and pelvic muscle weakness may explain the association between levator avulsion and pelvic organ prolapse., Study Design: This was a supplementary study of a longitudinal cohort of parous women enrolled 5-10 years after first delivery and assessed annually for prolapse (defined as descent beyond the hymen) for up to 9 annual visits. For this substudy, vaginally parous participants were assessed for levator avulsion using 3-dimensional transperineal ultrasound. Ultrasound was performed at a median interval of 11 years from delivery. Ultrasound volumes also were used to measure levator hiatus area with Valsalva. Pelvic muscle strength was measured with perineometry. Women with and without pelvic organ prolapse were compared for levator avulsion, levator hiatus area, and pelvic muscle strength, using multivariable logistic regression yielding a measure of mediation. Bootstrap methods were used to calculate the confidence interval corresponding to the measure of mediation by hiatus area and pelvic muscle strength., Results: Prolapse was identified in 109 of 429 (25%) and was significantly associated with levator avulsion (odds ratio, 4.17; 95% confidence interval, 2.28-7.31). Prolapse also was associated with levator hiatus area (odds ratio, 1.52 per 5 cm 2 ; 95% confidence interval, 1.34-1.73) and inversely with muscle strength (odds ratio, 0.87 per 5 cm H 2 O; 95% confidence interval, 0.81-0.94). In a multivariable logistic model including levator avulsion, levator hiatus area, and strength, the association between levator avulsion and prolapse was substantially attenuated and indeed was no longer statistically significant (odds ratio, 1.75; 95% confidence interval, 0.91-3.39). Hiatus area and strength mediated 61% (95% confidence interval, 34%-106%) of the association between avulsion and prolapse. Furthermore, since the 95% confidence interval for this estimate contained 100%, it cannot be ruled out that the 2 markers fully mediate the effect of avulsion on prolapse., Conclusions: The strong association between pelvic organ prolapse and levator avulsion can be explained to a large extent by a larger levator hiatus and weaker pelvic muscles after levator avulsion., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: With vaginal childbirth, 10% to 30% of women sustain levator ani muscle avulsion. The objective of this study was to estimate the cumulative incidence of prolapse and other pelvic floor disorders (PFDs), comparing vaginally parous women with and without levator avulsion., Methods: Parous women enrolled in a longitudinal study were assessed annually for PFDs with the Pelvic Organ Prolapse Quantification Examination (for prolapse) and the Epidemiology of Prolapse and Incontinence Questionnaire (for stress incontinence, overactive bladder, and anal incontinence). Three-dimensional transperineal ultrasound was used to identify levator avulsion. Women with and without levator avulsion after vaginal delivery were compared for the cumulative incidence of PFDs. Further analysis also stratified by forceps delivery., Results: At the time of assessment, 453 participants were 6 to 17 years from first delivery (median, 11 years). Levator avulsion was identified in 15% (66/453) and was more common among those who had undergone forceps-assisted delivery (P < 0.001). Levator avulsion was strongly associated with prolapse beyond the hymen (odds ratio, 2.7; 95% confidence interval, 1.3-5.7) and with symptoms of prolapse (odds ratio, 3.0; 95% confidence interval-1.2, 7.3). These associations persisted after controlling for forceps-assisted delivery. In contrast, the odds of stress incontinence, overactive bladder, and anal incontinence were marginally (but not significantly) increased among women with levator avulsion in this cohort., Conclusions: Obstetric levator avulsion is strongly associated with pelvic organ prolapse. The relationship between levator avulsion and other PFDs may not be significant.

Importance: Pelvic floor disorders (eg, urinary incontinence), which affect approximately 25% of women in the United States, are associated with childbirth. However, little is known about the course and progression of pelvic floor disorders over time., Objective: To describe the incidence of pelvic floor disorders after childbirth and identify maternal and obstetrical characteristics associated with patterns of incidence 1 to 2 decades after delivery., Design, Setting, and Participants: Women were recruited from a community hospital for this cohort study 5 to 10 years after their first delivery and followed up annually for up to 9 years. Recruitment was based on mode of delivery; delivery groups were matched for age and years since first delivery. Of 4072 eligible women, 1528 enrolled between October 2008 and December 2013. Annual follow-up continued through April 2017., Exposures: Participants were categorized into the following mode of delivery groups: cesarean birth (cesarean deliveries only), spontaneous vaginal birth (≥1 spontaneous vaginal delivery and no operative vaginal deliveries), or operative vaginal birth (≥1 operative vaginal delivery)., Main Outcomes and Measures: Stress urinary incontinence (SUI), overactive bladder (OAB), and anal incontinence (AI), defined using validated threshold scores from the Epidemiology of Prolapse and Incontinence Questionnaire, and pelvic organ prolapse (POP), measured using the Pelvic Organ Prolapse Quantification Examination. Cumulative incidences, by delivery group, were estimated using parametric methods. Hazard ratios, by exposure, were estimated using semiparametric models., Results: Among 1528 women (778 in the cesarean birth group, 565 in the spontaneous vaginal birth group, and 185 in the operative vaginal birth group), the median age at first delivery was 30.6 years, 1092 women (72%) were multiparous at enrollment (2887 total deliveries), and the median age at enrollment was 38.3 years. During a median follow-up of 5.1 years (7804 person-visits), there were 138 cases of SUI, 117 cases of OAB, 168 cases of AI, and 153 cases of POP. For spontaneous vaginal delivery (reference), the 15-year cumulative incidences of pelvic floor disorders after first delivery were as follows: SUI, 34.3% (95% CI, 29.9%-38.6%); OAB, 21.8% (95% CI, 17.8%-25.7%); AI, 30.6% (95% CI, 26.4%-34.9%), and POP, 30.0% (95% CI, 25.1%-34.9%). Compared with spontaneous vaginal delivery, cesarean delivery was associated with significantly lower hazard of SUI (adjusted hazard ratio [aHR], 0.46 [95% CI, 0.32-0.67]), OAB (aHR, 0.51 [95% CI, 0.34-0.76]), and POP (aHR, 0.28 [95% CI, 0.19-0.42]), while operative vaginal delivery was associated with significantly higher hazard of AI (aHR, 1.75 [95% CI, 1.14-2.68]) and POP (aHR, 1.88 [95% CI, 1.28-2.78]). Stratifying by delivery mode, the hazard ratios for POP, relative to a genital hiatus size less than or equal to 2.5 cm, were 3.0 (95% CI, 1.7-5.3) for a genital hiatus size of 3 cm and 9.0 (95% CI, 5.5-14.8) for a genital hiatus size greater than or equal to 3.5 cm., Conclusions and Relevance: Compared with spontaneous vaginal delivery, cesarean delivery was associated with significantly lower hazard for stress urinary incontinence, overactive bladder, and pelvic organ prolapse, while operative vaginal delivery was associated with significantly higher hazard of anal incontinence and pelvic organ prolapse. A larger genital hiatus was associated with increased risk of pelvic organ prolapse independent of delivery mode.

Background: There is limited knowledge of the effects of time on change in pelvic floor muscle strength after childbirth., Objective: The objectives of this study were to estimate the change in pelvic floor muscle strength in parous women over time and to identify maternal and obstetric characteristics associated with the rate of change., Study Design: This is an institutional review board-approved prospective cohort study of parous women. Participants were recruited 5-10 years after first delivery and followed annually. Pelvic floor muscle strength (peak pressure with voluntary contraction) was measured at 2 annual visits approximately 4 years apart with the use of a perineometer. We calculated the change in peak pressures, which were standardized per 5-year interval. Linear regression was used to identify maternal and obstetric characteristics that are associated with the rate of change in peak pressure. The obstetric variable of greatest interest was delivery group. Participants were classified into 3 delivery groups (considering all deliveries for each multiparous woman). Delivery categories included cesarean only, at least 1 vaginal birth but no forceps-assisted deliveries, and at least 1 forceps-assisted vaginal birth. Statistical analysis was completed with statistical software., Results: Five hundred forty-three participants completed 2 perineometer measurements with a median 4 years between measures (interquartile range, 3.1-4.8). At initial measurement, women were, on average, 40 years old and 8 years from first delivery. Initial strength was higher in participants who delivered all their children by cesarean (38.5 cm H 2 O) as compared with women with any vaginal non-forceps delivery (26.0 cm H 2 O) or vaginal forceps delivery (13.5 cm H 2 O; P<.001). There was a strong correlation between the first and second perineometry measurement (r=0.84). Median change in pelvic floor muscle strength was small at 1.2 cm H 2 O per 5 years (interquartile range, -5.6, 9.9 cm H 2 O). In multivariable analysis, women who delivered by cesarean only demonstrated almost no change in strength over 5 years (0.2 increase cm H 2 O per 5 years); those who experienced at least 1 vaginal or vacuum delivery increased strength (4.8 cm H 2 O per 5 years) as did women with at least 1 forceps delivery (5.0 cm H 2 O per 5 years). Additionally, obese women had a significant reduction in strength (-3.1 cm H 2 O per 5 years) compared with normal weight participants (0.2 cm H 2 O per 5 years)., Conclusion: Among parous women, pelvic muscle strength increased minimally over time with an average change of 1.2 cm H 2 O per 5 years; change in strength was associated with mode of delivery and obesity., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Pelvic organ prolapse is more common among parous (vs nulliparous) women and also more common after vaginal (vs cesarean) birth. However, very little is known about how childbirth affects the course and progression of the genital hiatus across a woman's life span., Objective: The objective of the sttudy was to investigate the longitudinal, quantitative changes in pelvic organ support after childbirth, focusing on the impact of vaginal vs cesarean delivery., Study Design: This was a prospective longitudinal cohort study in which parous women were recruited 5-10 years from first delivery and followed up annually. Using data from annual pelvic organ prolapse quantification examinations, we considered changes in vaginal support at the anterior vaginal wall (point Ba), the vaginal apex (point C), and the posterior wall (point Bp). In univariate and multivariable models, we compared pelvic organ support between women who had delivered at least 1 child vaginally vs those delivered exclusively by cesarean. Other covariates considered included race, age at first delivery, and the size of the genital hiatus. For models of support at Ba and Bp, we also considered the independent association with apical support. For women who delivered vaginally, we also considered forceps birth., Results: A total of 1224 women participated for a total of 7055 woman-visits. In multivariable models, vaginal birth was associated with significantly worse support 5 years from first delivery. Also, women with at least 1 vaginal birth had more rapid worsening of support at point C. The width of the genital hiatus was a significant independent predictor of worse support 5 years from delivery as well as the rate of change over time. In models that controlled for the genital hiatus, the strength of the impact of vaginal birth was attenuated., Conclusion: Vaginal birth was associated with worse support 5 years from first delivery and with more rapid deterioration in support at the apex. Above and beyond the impact of vaginal birth, the size of the genital hiatus may be an independent marker for those at greatest risk of prolapse progression., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Maternal satisfaction with the birth experience is multidimensional and influenced by many factors, including mode of delivery. To date, few studies have investigated maternal satisfaction outside of the immediate postpartum period., Objective: This study investigated whether differences in satisfaction based on mode of delivery are observed more than a decade after delivery., Study Design: This was a planned, supplementary analysis of data collected for the Mothers' Outcomes after Delivery study, a longitudinal cohort study of pelvic floor disorders in parous women and their association with mode of delivery. Obstetric and demographic data were obtained through patient surveys and obstetrical chart review. Maternal satisfaction with childbirth experience was assessed via the Salmon questionnaire, administered to Mothers' Outcomes after Delivery study participants >10 years from their first delivery. This validated questionnaire yields 3 scores: fulfillment, distress, and difficulty. These 3 scores were compared by mode of delivery (cesarean prior to labor, cesarean during labor, spontaneous vaginal delivery, and operative vaginal delivery). In addition, the impact of race, age, education level, parity, episiotomy, labor induction, and duration of second stage of labor on maternal satisfaction were examined., Results: Among 576 women, 10.1-17.5 years from delivery, significant differences in satisfaction scores were noted by delivery mode. Salmon scale scores differed between women delivering by cesarean and those delivering vaginally: women delivering vaginally reported greater fulfillment (0.40 [-0.37 to 0.92] vs 0.15 [-0.88 to 0.66], P < .001) and less distress (-0.34 [-0.88 to 0.38] vs 0.20 [-0.70 to 0.93], P < .001) than those who delivered by cesarean. Women who delivered by cesarean prior to labor reported the greatest median fulfillment scores and the lowest median difficulty scores. Median distress scores were lowest among those who delivered by spontaneous vaginal birth. Among women who underwent cesarean delivery, labor induction and prolonged second stage were associated with higher difficulty scores. These factors did not affect satisfaction scores among women who delivered vaginally. Among women who delivered vaginally, operative vaginal delivery was associated with less favorable scores across all 3 scores., Conclusion: Maternal satisfaction with childbirth is influenced by mode of delivery. The birth experience leaves an impression on women more than a decade after delivery., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Posterior vaginal prolapse is thought to cause difficult defecation and splinting for bowel movements. However, the temporal relationship between difficult defecation and prolapse is unknown. Does posterior vaginal prolapse lead to the development of defecation symptoms? Conversely, does difficult defecation lead to posterior prolapse? This prospective longitudinal study offered an opportunity to study these unanswered questions., Objective: We sought to investigate the following questions: (1) Are symptoms of difficult defecation more likely to develop (and less likely to resolve) among women with posterior vaginal prolapse? (2) Is posterior vaginal prolapse more likely to develop among women who complain of difficult defecation?, Study Design: In this longitudinal study, parous women were assessed annually for defecatory symptoms (Epidemiology of Prolapse and Incontinence Questionnaire) and pelvic organ support (POP-Q examination). The unit of analysis for this study was a visit-pair (2 sequential visits from any participant). We created logistic regression models for symptom onset among those women who were symptom-free at the index visit and for symptom resolution among those women who had symptoms at the index visit. To investigate the change in posterior vaginal support (assessed at point Bp) as a function of symptom status, we created a standard regression model that controlled for Bp at the index visit for each visit-pair., Results: We derived 3888 visit-pairs from 1223 women (each completed 2-7 annual visits). At the index visit, 1143 women (29%) reported difficulty with bowel movements, and 643 women (17%) reported splinting for bowel movements. Posterior vaginal prolapse (Bp≥0) was observed among 80 women (2%). Among those women without symptoms, posterior vaginal prolapse did not significantly increase the odds that defecatory symptoms would develop (difficult bowel movements, P=.378; splinting, P=.765). In contrast, among those with defecatory symptoms, posterior vaginal prolapse reduced the probability of symptom resolution (difficult bowel movements, P<.001; splinting, P=.162). The mean rate of change in posterior wall support was +0.13 cm. Among women without posterior vaginal prolapse, the presence of defecatory symptoms at the index visit did not have an effect on changes in Bp over time; however, among those with posterior vaginal prolapse (Bp≥0), defecatory symptoms were associated with more rapid worsening of posterior support (difficulty with bowel movements, P=.005; splinting, P=.057)., Conclusion: Posterior vaginal prolapse did not increase the odds that new defecatory symptoms would develop among asymptomatic women but did increase the probability that defecatory symptoms would persist over time. Furthermore, among those women with established posterior vaginal prolapse, defecatory symptoms were associated with more rapid worsening of posterior vaginal wall descent., (Copyright © 2016 Elsevier Inc. All rights reserved.)

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., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: The aim of this prospective study was to investigate whether symptoms of incontinence and prolapse bias maternal recall of obstetrical events up to 10 years after delivery., Methods: In this secondary analysis of data gathered from the Mothers' Outcomes After Delivery study, we compared obstetrical medical records with maternal recall of delivery events. We calculated the agreement between maternal recall and the medical record across 1821 deliveries from 1011 participants for events including macrosomia, mode of delivery, prolonged second of labor, episiotomy, spontaneous laceration, anal sphincter laceration, and operative delivery. Women with symptomatic pelvic floor disorders were identified through administration of the Epidemiology of Prolapse and Incontinence Questionnaire or a clinical history of therapy for a pelvic floor disorder. We determined whether agreement between maternal recall and the medical record differed for those with or without symptoms using the medical record as a criterion standard., Results: Agreement between maternal recall and the medical record was excellent for macrosomia and forceps deliveries (κ > 0.8), fair to good for episiotomy (κ = 0.61) and anal sphincter laceration (κ = 0.57), and poor for spontaneous perineal laceration (κ = 0.41). Symptomatic pelvic floor disorders did not impact maternal recall of macrosomia, prolonged second stage, episiotomy, spontaneous laceration, or operative delivery. However, recall of anal sphincter lacerations was biased by symptoms of pelvic floor disorders. Specifically, symptomatic women were significantly more likely to report a history of anal sphincter laceration, regardless of whether a sphincter laceration was documented (P = 0.025)., Conclusions: Maternal recall of anal sphincter laceration may be biased by symptomatic pelvic floor disorders. In research based on maternal recall of obstetrical events, this could strengthen the apparent association between sphincter laceration and pelvic floor disorders.

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.

Aims: To describe longitudinal changes in symptoms of overactive bladder (OAB) and stress urinary incontinence (SUI) among parous women., Methods: At annual examinations, beginning at least 5 years from first delivery, OAB and SUI were assessed using the Epidemiology of Prolapse and Incontinence Questionnaire. Published thresholds were used to define "bothersome" symptom scores. The prevalence, the incidence of bothersome symptoms, and treatment rates were calculated. In separate analyses for women who delivered by cesarean versus vaginal delivery, odds of SUI or OAB symptoms (score > 0) were modeled as a function of time since childbirth, age, race, and obesity. Among those with persistent symptoms, severity symptom score was modeled as a function of time since childbirth and these same covariates., Results: One thousand four hundred and eighty-one participants completed up to 5 annual assessments (2,722 woman-years). During follow-up, the incidences of bothersome SUI and OAB were 2.5/100 woman-years and 1.7/100 woman-years, respectively. Although SUI and OAB symptoms were more common in the vaginal birth group (P < 0.001), the odds of symptoms increased since increasing time from delivery in the cesarean group. Symptom severity did not change substantially over time in either group. Obesity was strongly associated with symptoms related to SUI and OAB., Conclusions: Five years from first delivery, symptoms related to SUI and OAB were more common and of greater severity after vaginal than cesarean birth. However, differences between these two groups lessen as time from childbirth increases. Obesity control should be a primary target for reduction of incontinence and incontinence severity among parous women., (© 2014 Wiley Periodicals, Inc.)

Study Question: When compared with vaginal delivery, is Cesarean delivery associated with reduced childbearing, a prolonged inter-birth interval or infertility?, Summary Answer: Women whose first delivery was by Cesarean section were not significantly different from those who delivered vaginally with respect to subsequent deliveries, inter-birth interval or infertility after delivery., What Is Already Known: Some studies have suggested that delivery by Cesarean section reduces subsequent fertility, while others have reported no association., Study Design, Size, Duration: This was a planned secondary analysis of the Mothers' Outcomes After Delivery study, a longitudinal cohort study. This analysis included 956 women with 1835 deliveries, who completed a study questionnaire at 6-11 years (median [interquartile range]: 8.1 [7.1, 9.8]) after their first delivery., Participants/materials, Setting, Methods: Exclusion criteria regarding the first birth were: maternal age <15 or >50 years, delivery at <37 weeks gestation, placenta previa, multiple gestation, known fetal congenital abnormality, stillbirth, prior myomectomy and abruption. Of the 956 women included, the first delivery was by Cesarean section for 534 women and by vaginal birth for 422 women. Infertility was self-reported. To compare maternal characteristics by mode of first delivery, P-values were calculated using Fisher's exact test or Pearson's χ(2) test for categorical variables and a Kruskall-Wallis test for continuous variables. We also considered whether, across all deliveries to date, a prior Cesarean is associated with decreased fertility. In this analysis, self-reported infertility after each delivery (across all participants) was considered as a function of one or more prior Cesarean births, using generalized estimating equations to control for within-woman correlation., Main Results and the Role of Chance: No differences were observed between the Cesarean and vaginal groups (for first delivery) with respect to infertility after their most recent delivery (7 versus 6%, P = 0.597), the interval between their first and second births (30.8 versus 30.6 months, P = 0.872), or multiparity (75 versus 76%, P = 0.650). Across all births, a history of Cesarean delivery was not significantly associated with infertility (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.64-1.26). Women who reported infertility prior to their first delivery were significantly more likely to report infertility after each subsequent delivery (OR, 5.16; 95% CI, 3.60-7.39)., Limitations, Reasons for Caution: Due to the use of self-reported infertility, the fertility status of some participants may be misclassified. Also, the small sample size may result in insufficient power to detect small differences between groups. Finally, a relatively high proportion of our participants were over age 35 at the time of first delivery (26%) and highly educated (37% with graduate degrees), which may indicate that our population may not be generalizable., Wider Implications of the Findings: While some prior studies have shown decreased family size among women who deliver by Cesarean, our results suggest that the rate of infertility is not different after Cesarean compared with vaginal birth. Our findings should be reassuring to women who deliver by Cesarean section., Study Funding/competing Interests: This study was funded by the US National Institutes of Health (NIH, R01-HD056275). No competing interests are declared., Trial Registration Number: N/A., (© The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: We sought to determine the long-term effect of mode of delivery on the prevalence and severity of pelvic pain., Study Design: Six to eleven years after a first delivery, pelvic pain (dysmenorrhea, dyspareunia, and pelvic pain not related to menses or intercourse) was measured using the Oxfordshire Women's Health Study Questionnaire. Obstetrical exposures were assessed by review of the hospital delivery record. The prevalence of moderate to severe pelvic pain was compared between the 577 women who delivered via cesarean for all births and the 538 who delivered at least 1 child vaginally. Other obstetrical exposures were also studied., Results: Prevalence of pelvic pain was similar between women who delivered vaginally and by cesarean. Among women who delivered vaginally, those who experienced at least 1 forceps delivery and women who delivered at least 1 baby ≥4 kg vaginally reported a higher rate of dyspareunia. Perineal trauma was not associated with dyspareunia., Conclusion: Forceps delivery and a vaginal delivery of a baby ≥4 kg are associated with dyspareunia 6-11 years after vaginal birth. Vaginal birth is not associated with a higher rate of pelvic pain when compared to cesarean delivery., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Introduction and Hypothesis: Benign joint hypermobility syndrome may be a risk factor for pelvic floor disorders. It is unknown whether hypermobility impacts the progress of childbirth, a known risk factor for pelvic floor disorders. Our objective was to investigate the association between joint hypermobility syndrome, obstetrical outcomes, and pelvic floor disorders. Our hypotheses were: (1) women with joint hypermobility are less likely to experience operative delivery and prolonged second-stage labor; and (2) pelvic floor disorders are associated with benign hypermobility syndrome, controlling for obstetrical history., Methods: Joint hypermobility was measured in 587 parous women (participants in a longitudinal cohort study of pelvic floor disorders after childbirth). Their obstetrical histories were obtained from review of hospital records. Pelvic floor disorders were assessed using validated questionnaires and a structured examination for prolapse. Joint hypermobility and pelvic floor disorders were evaluated at enrollment (5-10 years after first delivery). We compared obstetrical outcomes and pelvic floor disorders between women with and without joint hypermobility, defined as a Beighton score ≥ 4., Results: Hypermobility was diagnosed in 46 women (7.8 %) and was associated with decreased odds of cesarean after complete cervical dilation or operative vaginal delivery [odds ratio (OR)=0.51; 95 % confidence interval (CI):0.27-0.95]. Anal sphincter laceration was unlikely to occur in women with hypermobility (OR=0.19; 95 % CI 0.04-0.80). However, hypermobility was not associated with any pelvic floor disorder considered., Conclusions: Benign joint hypermobility syndrome may facilitate spontaneous vaginal birth but does not appear to be a risk factor for pelvic floor disorders in the first decade 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., (Copyright © 2012 Mosby, Inc. All rights reserved.)

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.

To investigate maternal characteristics associated with breastfeeding initiation and success. Women enrolled in the Mothers Outcomes After Delivery study reported breastfeeding practices 5-10 years after a first delivery. Women were classified as successful breastfeeding initiators, unsuccessful initiators, or non-initiators. For the first birth, demographic and obstetrical characteristics were compared across these three breastfeeding groups. For multiparous women, agreement in breastfeeding status between births was evaluated. Multivariate regression analysis was used to identify characteristics associated with non-initiation and unsuccessful breastfeeding across all births. Of 812 participants, 740 (91%) mothers tried to breastfeed their first child and 593 (73%) reported breastfeeding successfully. In a multivariate analysis, less educated women were less likely to initiate breastfeeding (odds ratio (OR) for non-initiation 1.97; 95% confidence interval (CI) 1.23, 3.14). There was a notable decrease in breastfeeding initiation with increasing birth order: compared to the first birth, the odds for non-initiation after a second delivery almost doubled (OR 1.83, 95% CI 1.42, 2.35) and the odds for non-initiation after a third delivery were further increased (OR 2.44, 95% CI 1.56, 3.82). Successful breastfeeding in a first pregnancy was a predictor of subsequent breastfeeding initiation and success. Specifically, women who did not attempt breastfeeding or who reported unsuccessful attempts to breastfeed at first birth were unlikely to initiate breastfeeding at later births. Cesarean delivery was not associated with breastfeeding initiation (OR 1.01; 95% CI 0.68, 1.48) or success (OR 1.33; 95% CI 0.92, 1.94). Breastfeeding practices after a first birth are a significant predictor of breastfeeding in subsequent births.

Aim: The objective of this study was to identify maternal, obstetrical and reproductive factors associated with long-term changes in maternal weight after delivery., Materials & Methods: Participants were enrolled in a longitudinal cohort study of maternal health 5-10 years after childbirth. Data were obtained from obstetrical records and a self-administered questionnaire. Weight at the time of first delivery (5-10 years prior) was obtained retrospectively and each woman's weight at the time of her first delivery was compared with her current weight., Results: Among 948 women, obesity was associated with race, parity, education, history of diabetes and history of cesarean at the time of first delivery. On average, the difference between weight at the time of first delivery and weight 5-10 years later was -11 kg (11 kg weight loss). In a multivariate model, black race and diabetes were associated with significantly less weight loss. Cesarean delivery, parity and breastfeeding were not associated with changes in maternal weight., Conclusion: Black women and those with a history of diabetes may be appropriate targets for interventions that promote a long-term healthy weight after childbirth.

Objective: The objective of this study was to characterize changes in pelvic organ support and symptoms of prolapse over time and identify characteristics associated with worsening of support., Methods: Participants were recruited based on the mode of delivery (cesarean vs vaginal delivery) of their first child. The Pelvic Organ Prolapse Quantification system was used to describe support at baseline and 12 to 18 months later. Symptoms were assessed using a validated questionnaire. Outcomes of interest included the proportion of women with a change in support greater than 1 cm at the anterior vaginal wall (Ba) or posterior vaginal wall (Bp) and a change in support greater than 2 cm at the apex (C). Characteristics associated with worsening of support were identified using 2-sided Fisher's exact test and multivariable logistic regression., Results: Among 749 participants, 60% had delivered by cesarean delivery only. Worsening support at Ba, Bp, and C was observed in 8%, 2%, and 6%, respectively. Worsening at any point was observed in 110 women (15%). Women with prolapse symptoms at baseline were not more likely to experience worsening of support. In a multivariable model, age older than 40 years (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.09-2.49), vaginal delivery (OR, 3.12; 95% CI, 1.38-7.07), and genital hiatus greater than or equal to 2 (OR, 2.36; 95% CI, 1.03-5.43) were all associated with worsening support in at least 1 compartment., Conclusions: Over 12 to 18 months, characteristics most strongly associated with worsening of pelvic support include genital hiatus size, vaginal birth, and age.

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.

We describe maternal childbirth goals among women planning either cesarean or vaginal birth. Women in the third trimester planning cesarean or vaginal birth were asked to report up to five childbirth goals. Goal achievement was assessed postpartum. Based on free-text responses, discrete goal categories were identified. Goals and goal achievement were compared between the two groups. Satisfaction was rated on a visual analogue scale and was compared with goal achievement. The sample included 163 women planning vaginal birth and 69 women planning cesarean. Twelve goal categories were identified. Only women planning vaginal birth reported a desire to achieve fulfillment related to childbirth. Women planning cesarean were less likely to express a desire to maintain control over their own responses during childbirth and more likely to report a desire to avoid complications. The 72 women who achieved all stated goals reported significantly higher mean satisfaction scores than the 94 women reporting that at least one goal was not achieved (P  =  0.001). Goal achievement was higher among women planning cesarean than among those planning vaginal birth (52.2% versus 23.1%, P  <  0.001). This research furthers our understanding of women's attitudes regarding cesarean childbirth and definitions of a successful birth experience., (© Thieme Medical Publishers.)

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., (© Thieme Medical Publishers.)

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.

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.

Objective: The purpose of this study was to compare anticipatory and postprocedure pain perception in female patients who undergo multichannel urodynamic evaluation in an office setting., Study Design: One hundred consecutive patients completed a visual analogue pain scale before and after urodynamic testing., Results: The mean postprocedure pain score of 2.32 cm was significantly lower than the anticipatory pain rating of 4.35 cm (P<.05). The lower postprocedure pain score was not influenced by previous hysterectomy, body mass index, menopausal status, estrogen replacement therapy, or analgesic or psychiatric medication usage. Patients who had undergone previous anti-incontinence surgery reported significantly higher levels of pain during the procedure (mean visual analogue pain scale score, 3.10 cm vs 2.06 cm; P=.027)., Conclusion: Patients who undergo urodynamic testing anticipate higher degrees of discomfort than they perceive during the procedure. Previous anti-incontinence surgery appears to lower the pain threshold.

Objective: The purpose of this study was to compare anticipated pain before the procedure and actual pain rating after the procedure in female patients who undergo cystourethroscopy., Study Design: Eighty-seven consecutive female patients completed a 10-cm visual analog pain scale before and after cystourethroscopy. A 24F urethroscope was used initially to inspect the urethra and was followed by a systematic survey of the bladder with a 17F cystoscope that was lubricated with 2% lidocaine gel. The visual analog pain scale scores were evaluated for significance with the use of the Student t test and the Pearson correlation coefficient., Results: Visual analog pain scale analysis demonstrated a mean anticipated pain score of 3.75 cm before the procedure versus a mean pain rating score of 2.83 cm after the procedure (P <.05). Neither a history of previous cystoscopy (visual analog pain scale score, 3.03 vs 2.30 cm; P =.18) nor talking with someone about the procedure beforehand (visual analog pain scale score, 2.74 vs 2.89 cm; P =.76) influenced the lower pain rating after the procedure. There was no significant correlation between age, parity, body mass index, or presence of pelvic organ prolapse and anticipated or realized pain perception., Conclusion: Patients who undergo cystourethroscopy consistently anticipate higher degrees of discomfort than they actually perceive during the procedure.