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Objective To determine if the addition of the assessment of levator ani muscle (LAM) avulsion to the measurement of the difference in the pubis-uterine fundus distance between rest and with the Valsalva maneuver could increase the diagnostic capacity of ultrasound for uterine prolapse (UP). Methods This multicenter, observational and prospective study included 145 patients. Ultrasound assessment was performed, establishing the diagnosis of UP as a difference between the pubic-uterine fundus distance at rest and during the Valsalva maneuver ≥15 mm (standard technique), while LAM avulsion was defined as an abnormal LAM insertion in three central slices using multislice ultrasound. A binary multivariate logistic regression model was made using nonautomated methods to predict surgical UP (general population, premenopausal, and postmenopausal patients), including the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver as well as LAM avulsion. Results A total of 143 patients completed the study. The addition of LAM avulsion criteria to the standard dynamic distance-based protocol for the diagnosis of UP resulted in a higher sensitivity for the general population (79.7 vs 68.1%) as well as for premenopausal (89.3 vs 79.9%) and postmenopausal patients (76 vs 66.1%). In contrast, the standard technique showed a higher specificity than the model based on the standard technique associated with LAM avulsion for the general population (89.2 vs 74.3%) and premenopausal women (91.7 vs 63.2%). For postmenopausal patients, the model based on the standard technique associated with LAM avulsion had a higher sensitivity (76 vs 66.1%) and specificity (91.7 vs 86.8%) than the ultrasound diagnosis of UP. Conclusion The implementation of the assessment of LAM avulsion in the ultrasound diagnosis of UP is useful in postmenopausal patients, increasing sensitivity and specificity relative to the ultrasound assessment based only on the difference between

Objectives—It is unknown whether diagnosing uterine prolapse (UP) via ultrasound or surgical criteria is superior. Our objective is to determine whether the diagnostic capacity of ultrasound with surgical criteria differs from that of surgical criteria only. Methods—This was a multicenter prospective observational study with 54 premenopausal patients with surgical criteria for a dysfunctional pelvic floor pathology who were consecutively recruited for 1 year. Clinical UP with surgical criteria was defined when UP stage II–IV was identified (during pelvic floor consultation), and UP diagnosed by ultrasound with surgical criteria was established when a difference ≥15 mm was found between rest and Valsalva applied to the pubis-uterine fundus. The sensitivity, specificity and positive and negative predictive values were determined to evaluate clinical and ultrasound methodologies as diagnostic tests. Results—UP diagnosed by ultrasound with surgical criteria presented better sensitivity (78.57 vs 35.71%), specificity (92.11 vs 81.58%), positive predictive value (61.83 vs 23.99%), and negative predictive value (96.35 vs 11.37%) than UP diagnosed by surgical criteria only. Conclusion—Ultrasound with surgical criteria is superior to surgical criteria alone when diagnosing UP.

Objectives The objective of this study is to investigate a multicenter study to establish if differences exist in the levator ani muscle avulsion (LAM) rates between deliveries performed with Malmstrom's vacuum and the Kiwi vacuum. Study design A prospective, multicenter observational study with 199 primiparous subjects was performed. All patients had undergone vaginal delivery by vacuum (Malmstrom's or Kiwi). Avulsion was defined as an abnormal insertion of LAM in the lower pubic branch in the multiplanar mode, as identified in the three central sections by transperineal 3/4D echography 6 months after delivery. The area of ​​the levator hiatus was measured in the plane of minimum dimensions at rest, during the Valsalva maneuver and during contraction. Results LAM avulsion occurred in 33.1% of cases in which Malmstrom's vacuum was used and in 29.4% of cases in which the Kiwi vacuum was used (the difference was not statistically significant), which resulted in a crude odds ratio (OR) of 0.977 (0.426, 2.241; P = .957) and an adjusted OR of 2.90 (0.691; 12.20; P = .146). Women in the Malmstrom's vacuum group had a larger LHA at rest 14.77 vs 12.64 cm2; P = .001) and at maximum contraction (13.41 vs 10.83 cm2; P < 0.001) in comparison with the Kiwi group, although the difference did not reach statistical significance under Valsalva maneuver (18.71 vs 17.21 cm2; P = .051).Differences between both groups were detected in the measurements of the hiatus area levator at rest (14.77 vs 12.64 cm2), during the Valsalva maneuver (18.71 vs 17.21 cm2) and during maximum contraction (13.41 vs 10.83 cm2). Conclusions In the present study, Malmstrom's vacuum was not associated with a higher risk of LAM in comparison with Kiwi's Omnicup.

Introduction: Forceps use is the main risk factor for levator ani muscle (LAM) injuries. We believe that the disengagement of the forceps branches before delivery of the fetal head could influence LAM injuries, so we aimed to determine the influence of the disengagement of the forceps on the occurrence of LAM avulsion during forceps delivery. Material and methods: A prospective, observational, multicenter study was conducted with 261 women who underwent forceps delivery. The women were classified according to whether the branches of the forceps had been disengaged before delivery of the fetal head. LAM avulsion was defined using a multislice mode (3 central slices). Results: In all, 255 women completed the study (160 without disengagement and 95 with disengagement). LAM avulsions were observed in 37.9% of women in the group with disengagement and in 41.9% of women in the group without disengagement. The crude OR (without disengagement vs with disengagement) for avulsion was 0.90 (95% CI 0.49-1.67, P = 0.757) and an adjusted OR of 0.82 (95% CI 0.40-1.69, P = 0.603). Conclusions: We did not observe a statistically significant reduction in the LAM avulsion rate with disengagement of the forceps branches before delivery of the fetal head.

[EN] Background: Caesarean section is necessary to save the lives of mothers and newborns at times, but it is important to perform it only when it is essential due to all the risks involved. This study aimed to examine the rate of caesarean sections performed at a tertiary hospital using the Robson classification to detect methods for the detection of and/or reduction in these caesarean section rates. Methods: A descriptive, cross-sectional study of a retrospective database was carried out. Results: A total of 10,317 births were assessed. The Robson classification was used to assess these interventions and verify whether the indication for performed caesarean sections was appropriate. In total, 2036 births by caesarean section were performed in the whole sample. The annual caesarean section rate varied between 18.67% and 21.18%. Conclusions: Caesarean sections increased by about 20% in 2021 compared to 2020 even though the trend over the years of study was decreasing. Vaginal delivery after caesarean section is a reasonable and safe option. Caesarean section rates could be improved, mostly in Robson’s Group 2. The Robson classification facilitated progress in the implementation of measures aimed at improving care and adjusting caesarean section rates.

La episiotomía es una incisión quirúrgica realizada en el periné durante el parto para facilitar el expulsivo. Su uso liberal en los partos instrumentales para prevenir los desgarros obstétricos del esfínter anal (OASIs) esta avalado por grandes estudios observacionales. Va a estar definida por tres parámetros: la distancia desde su inicio en introito hasta la horquilla vulvar, su ángulo, y su longitud, y la colocación exacta de la misma es un factor de riesgo de OASIs modificable. Nuestros objetivos fueron establecer una correlación entre las características de la episiotomía en el momento de la incisión y tras su sutura, seleccionar el patrón de sutura asociado a un menor riesgo de OASIs en los partos instrumentales y valorar si su optimización mediante el uso de Triepi-45 puede prevenir los OASIs en este tipo de partos. MATERIAL Y METODOS La presente tesis doctoral se presenta como un compendio de tres trabajos previamente publicados. En primer lugar, un estudio prospectivo descriptivo con 45 primíparas, en el cual se analizaron los cambios en el periné pre-marcado mediante dos fotografías digitales, una en reposo y otra con la cabeza coronando. En segundo lugar, un estudio de casos y controles retrospectivo con 958 partos instrumentales que fueron revisados en el puerperio, incluyendo dentro de los casos aquellos partos que sufrieron un OASIs. Y por ultimo, un estudio de cohorte retrospectivo-prospectivo tras la implantación del uso de Triepi-45, un dispositivo que permite el marcado con un ángulo de 45º del periné en reposo, con 986 partos instrumentales en cada grupo. RESULTADOS Cuando el periné se distiende durante el expulsivo, cada línea marcada así como su punto de inicio en la horquilla vulvar se desplaza lateralmente de manera lineal, y sin cambios significativos en el ángulo y la distancia a los puntos A y B. Sin embargo, si comparamos la configuración lineal original en reposo con unas líneas imaginarias desde la horquilla hasta los puntos A y B antes