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Episiotomy in vacuum extraction, do we cut the levator ani muscle? A prospective cohort study

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Abstract

Introduction and hypothesis

Vaginal delivery may lead to levator ani muscle (LAM) injury or avulsion. Episiotomy may reduce obstetric anal sphincter injury in operative vaginal delivery, but may increase the risk of LAM injury. Our aim was to assess whether lateral episiotomy in vacuum extraction (VE) in primiparous women causes LAM injury.

Methods

A prospective cohort study of 58 primiparous women with episiotomy nested within an ongoing multicenter randomized controlled trial of lateral episiotomy versus no episiotomy in VE (EVA trial) was carried out in Sweden. LAM injury was evaluated using 3D endovaginal ultrasound 6–12 months after delivery and Levator Ani Deficiency (LAD) score. Episiotomy scar properties were measured. Characteristics were described and compared using Chi-squared tests. We stipulated that if a lateral episiotomy cuts the LAM, ≥50% would have a LAM injury. Among those, ≥50% would be side specific. We compared the observed prevalence with a test of one proportion.

Results

Twelve (20.7%, 95% CI 10.9–32.9) of 58 women had a LAD (p < 0.001, compared with the stipulated 50%). Six (50.0%, 95% CI 21.1% to 78.9%) of 12 women had a LAD on the episiotomy side, including those with bilateral LAD (p = 1.00). Two (16.7%, 95% CI 2.1% to 48.4%) of 12 women had a LAD exclusively on the episiotomy side (p = 0.02).

Conclusions

There was no excessive risk of cutting the LAM while performing a lateral episiotomy. LAD was not seen in women with episiotomies shorter than 18 mm.

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References

  1. Lund NS, Persson LK, Jango H, Gommesen D, Westergaard HB. Episiotomy in vacuum-assisted delivery affects the risk of obstetric anal sphincter injury: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2016;207:193–9.

    Article  PubMed  Google Scholar 

  2. Sultan AH, Thakar R, Ismail KM, Kalis V, Laine K, Räisänen SH, et al. The role of mediolateral episiotomy during operative vaginal delivery. Eur J Obstet Gynecol Reprod Biol. 2019;240:192–6.

    Article  CAS  PubMed  Google Scholar 

  3. Eogan M, Daly L, O'Connell PR, O'Herlihy C. Does the angle of episiotomy affect the incidence of anal sphincter injury? BJOG. 2006;113(2):190–4.

    Article  CAS  PubMed  Google Scholar 

  4. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017;2:CD000081.

    PubMed  Google Scholar 

  5. Lima CTS, Brito GA, Karbage SAL, Bilhar APM, Grande AJ, Carvalho FHC, et al. Pelvic floor ultrasound finds after episiotomy and severe perineal tear: systematic review and meta-analysis. J Matern Fetal Neonatal Med. 2020. https://doi.org/10.1080/14767058.2020.1786049.

    Article  PubMed  Google Scholar 

  6. Tracy PV, DeLancey JO, Ashton-Miller JA. A geometric capacity-demand analysis of maternal levator muscle stretch required for vaginal delivery. J Biomech Eng. 2016;138(2):021001.

    Article  PubMed  Google Scholar 

  7. Thibault-Gagnon S, Yusuf S, Langer S, Wong V, Shek KL, Martin A, et al. Do women notice the impact of childbirth-related levator trauma on pelvic floor and sexual function? Results of an observational ultrasound study. Int Urogynecol J. 2014;25(10):1389–98.

    Article  PubMed  Google Scholar 

  8. Rusavy Z, Paymova L, Kozerovsky M, Veverkova A, Kalis V, Kamel RA, et al. Levator ani avulsion: a Systematic evidence review (LASER). BJOG. 2021;129(4):517–28.

    Article  PubMed  Google Scholar 

  9. Friedman T, Eslick GD, Dietz HP. Delivery mode and the risk of levator muscle avulsion: a meta-analysis. Int Urogynecol J. 2019;30(6):901–7.

    Article  PubMed  Google Scholar 

  10. Cassadó J, Simó M, Rodríguez N, Porta O, Huguet E, Mora I, et al. Prevalence of levator ani avulsion in a multicenter study (PAMELA study). Arch Gynecol Obstet. 2020;302(1):273–80.

    Article  PubMed  Google Scholar 

  11. Shobeiri SA, LeClaire E, Nihira MA, Quiroz LH, O'Donoghue D. Appearance of the levator ani muscle subdivisions in endovaginal three-dimensional ultrasonography. Obstet Gynecol. 2009;114(1):66–72.

    Article  PubMed  Google Scholar 

  12. Javadian P, O’Leary D, Rostaminia G, North J, Wagner J, Quiroz LH, et al. How does 3D endovaginal ultrasound compare to magnetic resonance imaging in the evaluation of levator ani anatomy? Neurourol Urodyn. 2017;36(2):409–13.

    Article  PubMed  Google Scholar 

  13. Kearney R, Sawhney R, DeLancey JOL. Levator ani muscle anatomy evaluated by origin-insertion pairs. Obstet Gynecol. 2004;104(1):168–73.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Van Delft K, Thakar R, Shobeiri SA, Sultan AH. Levator hematoma at the attachment zone as an early marker for levator ani muscle avulsion. Ultrasound Obstet Gynecol. 2014;43(2):210–7.

    Article  PubMed  Google Scholar 

  15. Jing D, Ashton-Miller JA, DeLancey JO. A subject-specific anisotropic visco-hyperelastic finite element model of female pelvic floor stress and strain during the second stage of labor. J Biomech. 2012;45(3):455–60.

    Article  PubMed  Google Scholar 

  16. Zhuang RR, Song YF, Chen ZQ, Ma M, Huang HJ, Chen JH, et al. Levator avulsion using a tomographic ultrasound and magnetic resonance-based model. Am J Obstet Gynecol. 2011;205(3):232.e1–8.

    Article  Google Scholar 

  17. Dietz HP, Shek KL, Daly O, Korda A. Can levator avulsion be repaired surgically? A prospective surgical pilot study. Int Urogynecol J. 2013;24(6):1011–5.

    Article  CAS  PubMed  Google Scholar 

  18. Kalis V, Laine K, de Leeuw JW, Ismail KM, Tincello DG. Classification of episiotomy: towards a standardisation of terminology. BJOG. 2012;119(5):522–6.

    Article  CAS  PubMed  Google Scholar 

  19. Bergendahl S, Ankarcrona V, Leijonhufvud A, Hesselman S, Karlstrom S, Kopp Kallner H, et al. Lateral episiotomy versus no episiotomy to reduce obstetric anal sphincter injury in vacuum-assisted delivery in nulliparous women: study protocol on a randomised controlled trial. BMJ Open. 2019;9(3):e025050.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Stedenfeldt M, Pirhonen J, Blix E, Wilsgaard T, Vonen B, Oian P. Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case-control study. BJOG. 2012;119(6):724–30.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Speksnijder L, Oom DMJ, Van Bavel J, Steegers EAP, Steensma AB. Association of levator injury and urogynecological complaints in women after their first vaginal birth with and without mediolateral episiotomy. Am J Obstet Gynecol. 2019;220(1):93.e1–9.

    Article  Google Scholar 

  22. Starck M, Bohe M, Valentin L. Results of endosonographic imaging of the anal sphincter 2–7 days after primary repair of third- or fourth-degree obstetric sphincter tears. Ultrasound Obstet Gynecol. 2003;22(6):609–15.

    Article  CAS  PubMed  Google Scholar 

  23. Starck M, Bohe M, Valentin L. Effect of vaginal delivery on endosonographic anal sphincter morphology. Eur J Obstet Gynecol Reprod Biol. 2007;130(2):193–201.

    Article  PubMed  Google Scholar 

  24. Rostaminia G, Manonai J, Leclaire E, Omoumi F, Marchiorlatti M, Quiroz LH, et al. Interrater reliability of assessing levator ani deficiency with 360° 3D endovaginal ultrasound. Int Urogynecol J. 2014;25(6):761–6.

    Article  CAS  PubMed  Google Scholar 

  25. Shek KL, Dietz HP. Intrapartum risk factors for levator trauma. BJOG. 2010;117(12):1485–92.

    Article  CAS  PubMed  Google Scholar 

  26. Valsky DV, Lipschuetz M, Bord A, Eldar I, Messing B, Hochner-Celnikier D, et al. Fetal head circumference and length of second stage of labor are risk factors for levator ani muscle injury, diagnosed by 3-dimensional transperineal ultrasound in primiparous women. Am J Obstet Gynecol. 2009;201(1):91.e1–7.

    Article  Google Scholar 

  27. Martinho N, Friedman T, Turel F, Robledo K, Riccetto C, Dietz HP. Birthweight and pelvic floor trauma after vaginal childbirth. Int Urogynecol J. 2019;30(6):985–90.

    Article  PubMed  Google Scholar 

  28. Cheng YW, Hopkins LM, Caughey AB. How long is too long: does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes? Am J Obstet Gynecol. 2004;191(3):933–8.

    Article  PubMed  Google Scholar 

  29. Leombroni M, Buca D, Liberati M, Falò E, Rizzo G, Khalil A, et al. Post-partum pelvic floor dysfunction assessed on 3D rotational ultrasound: a prospective study on women with first- and second-degree perineal tears and episiotomy. J Matern Fetal Neonatal Med. 2021;34(3):445–55.

    Article  PubMed  Google Scholar 

  30. Dietz HP. Ultrasound imaging of maternal birth trauma. Int Urogynecol J. 2021;32(7):1953–62.

    Article  PubMed  Google Scholar 

  31. Subramaniam N, Shek KL, Dietz HP. Imaging characteristics of episiotomy scars on translabial ultrasound: an observational study. J Ultrasound Med. 2021. https://doi.org/10.1002/jum.15915.

    Article  PubMed  Google Scholar 

  32. Dietz HP. Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol. 2007;29(3):329–34.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

We are deeply grateful to the women participating in the EVA trial and the obstetric staff who have contributed to the recruitment of study participants. We especially thank our research midwives Helen Fagraeus and Annelie Wikström, Danderyd Hospital, Stockholm, and Irina Sylve, Akademiska Hospital, Uppsala, Sweden.

Funding

This study was partly funded by the Swedish Research Council (grant number 2016-00526) and the Uppsala-Örebro Research Council (grant number RFR-939428).

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Authors and Affiliations

  1. Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden

    Victoria Ankarcrona & Sophia Brismar Wendel

  2. Department of Obstetrics and Gynecology, Danderyd Hospital, 182 88, Stockholm, Sweden

    Victoria Ankarcrona, Sissela Sylvan & Sophia Brismar Wendel

  3. Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Huddinge, Sweden

    Sofie Karlström

  4. Pelvic Floor Center, Department of Surgery, Skåne University Hospital, Malmö, Sweden

    Marianne Starck

  5. Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden

    Maria Jonsson

Authors
  1. Victoria Ankarcrona
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  2. Sofie Karlström
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  3. Sissela Sylvan
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  4. Marianne Starck
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  6. Sophia Brismar Wendel
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Contributions

V. Ankarcrona: project development, data collection and analyses, result analyses, manuscript writing and editing; S. Karlström: project development, data collection and analyses, manuscript writing; S. Sylvan: result analyses, language editing, manuscript editing; M. Starck: data analyses, result analyses, manuscript editing; M. Jonsson: data collection, result analyses, manuscript editing; S. Brismar Wendel: project development, data collection and analyses, manuscript writing and editing. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Victoria Ankarcrona.

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Ankarcrona, V., Karlström, S., Sylvan, S. et al. Episiotomy in vacuum extraction, do we cut the levator ani muscle? A prospective cohort study. Int Urogynecol J 33, 3391–3399 (2022). https://doi.org/10.1007/s00192-022-05188-4

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  • DOI: https://doi.org/10.1007/s00192-022-05188-4

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