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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 (pp=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% (pp=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.

Introduction and hypothesis Vaginal delivery may lead to tearing of the levator ani (LA) muscle from its bony insertions (complete LA avulsion) and increased levator hiatus (LH) area, both risk factors for pelvic floor dysfunctions. Early active rehabilitation is standard treatment after musculo-skeletal injury. We hypothesized that pelvic floor muscle training (PFMT) early postpartum would reduce the presence of LA avulsions and reduce LH area. Methods We carried out a planned secondary analysis from a randomized controlled study. Primiparous women (n=175) giving birth vaginally were included 6 weeks postpartum, stratified on complete LA avulsion, and thereafter randomized to PFMT or control. The training participants (n=87) attended a supervised PFMT class once a week and performed home-based PFMT daily for 16 weeks. The control participants (n=88) received no intervention. Presence of complete LA avulsion, LH area at rest, maximal contraction, and maximal Valsalva maneuver were assessed by transperineal ultrasound. Between-group comparisons were analyzed by analysis of covariance for continuous data, and relative risk (RR) for categorical data. Results Six months postpartum, the number of women who had complete LA avulsion was reduced from 27 to 14 within the PFMT group (44% reduction) and from 28 to 17 within the control group (39% reduction). The between-group difference was not significant, RR 0.85 (95% CI 0.53 to 1.37). Further, no significant between-group differences were found for LH area at rest, during contraction, or Valsalva. Conclusions Supervised PFMT class combined with home exercise early postpartum did not reduce the presence of complete LA avulsion or LH area more than natural remission.

Introduction The present study aimed first to investigate the change in prevalence of major levator ani muscle (LAM) defects, also called avulsions, from 6 weeks to 1 year postpartum, and second to assess maternal and obstetric risk factors for having persistent major LAM defects/avulsions at 1 year postpartum. Material and methods This is a secondary analysis of data from a prospective cohort study including 300 nulliparous women at 17-19 weeks of gestation. Major LAM defects were diagnosed at 6 weeks and 1 year postpartum using transperineal ultrasonography. We defined persistent major LAM defects as a defect diagnosed both at 6 weeks and 1 year postpartum. Maternal and obstetric data were obtained from the hospital's electronic birth records. Pelvic floor muscle function was measured vaginally by manometer at 21 weeks of gestation. The main outcome measurement was change in prevalence of major LAM defects. Maternal and obstetric risk factors for having persistent major LAM defect were also assessed. Results Prevalence of major LAM defects was 19.4% at 6 weeks and 10.4% at 1 year postpartum. No new major LAM defects were diagnosed at 1 year postpartum. Persisting major LAM defects were associated with longer second stage of labor (median 74.5 minutes vs median 48.0 minutes, P = .012) and higher neonatal birthweight (mean difference of 232.3 g, 95% confidence interval [CI] 21.5-443.1). Vacuum delivery was independently associated with persistent major LAM defects, adjusted OR 3.0 (95% CI 1.0-9.0). Conclusions There was a 50% reduction of sonographically diagnosed major LAM defects from 6 weeks to 1 year postpartum. This finding suggests that assessment of the major LAM 6 weeks postpartum may be too early to diagnose defects/avulsions. Long second stage of labor, high neonatal birthweight and vacuum delivery were associated with persistent major LAM defects/avulsions.

Introduction Second-degree perineal tears can vary widely as to the extent of trauma, which may be relevant for women's pelvic floor health postpartum. However, the short- and long-term consequences of second-degree perineal tears are poorly understood, likely due to the lack of a detailed classification system. Such a classification system for second-degree tears has been suggested but the inter-rater agreement has not yet been assessed. The aim of this study was to assess the inter-rater agreement of the already established classification system for perineal tears recommended by the Royal College of Obstetricians and Gynaecologists (RCOG classification) among midwives. Further, we aimed to assess the inter-rater agreement of a classification system that provides three sub-categories for second-degree perineal tears. Material and methods This was an inter-rater agreement study, conducted at Akershus University Hospital in Norway from 31 August to 29 November 2020. All midwives working in the delivery ward participated in the study. Midwives classified the integrity of the perineum of all women delivering vaginally within the study period. During the first month of the study, tears were classified by two midwives who were blinded to each other's findings, and the agreement of the RCOG classification was assessed. The following month, the detailed classification system was introduced to the midwifery staff. The last month, perineal tears were classified by two midwives using the detailed classification system, and the agreement was assessed. Inter-rater agreement was measured using Fleiss multirater kappa (k) and Kendall's coefficient of concordance (KCCw). Results The inter-rater agreement for the RCOG classification was good to very good, with k = 0.705 (95% confidence interval [CI] 0.62–0.79, P

Despite the strong association between vaginal childbirth and pelvic floor dysfunction, genetic factors, pregnancy, advancing age, and lifestyle also play a role. The pelvic floor undergoes substantial changes during pregnancy, which may contribute to pelvic floor dysfunction. Conversely, these changes may be favorable for vaginal delivery. However, there is a lack of studies assessing pelvic floor symptoms over time according to delivery mode and including predelivery assessment.This study aimed to describe urinary incontinence, vaginal symptoms, and bowel control symptoms from 21 weeks of gestation in the first pregnancy up to 8 years after the first delivery, stratified by delivery mode.This was a longitudinal observational cohort study. A total of 300 nulliparous women were recruited during their first pregnancy. Pelvic floor symptoms were assessed at 21 and 37 weeks of gestation, and at 6 weeks, 6 months, 12 months, and 8 years after first delivery using the International Consultation on Incontinence Questionnaire modules: the urinary incontinence sum score, the weighted vaginal symptom sum score, the vaginal-associated quality of life score, the bowel control sum score, and the bowel-associated quality of life sum score. Delivery mode at first delivery defined delivery groups as: normal vaginal, operative vaginal, and cesarean delivery. A linear mixed-model analysis was used to assess symptom scores over time and differences in symptom scores between the delivery groups.Of the 300 women included in the study, 193 attended the 8-year follow-up. Pelvic floor symptoms differed between women who had vaginal delivery and those who had cesarean delivery. The symptom scores showed a nonlinear statistically significant trend. In women who delivered vaginally, there was an increase of urinary incontinence and vaginal symptom scores already during pregnancy. In women who later delivered by cesarean, there was a decrease of symptom scores during pregnancy, and overall lower symptom scores relative to women who had vaginal delivery at 12 months after the first delivery. Pelvic floor symptom scores increased from 12 months to 8 years after the first delivery and exceeded pregnancy levels in all delivery groups; however, overall symptom scores were low. Differences between delivery groups were not statistically significant.Pelvic floor symptoms differed between women who had vaginal delivery and those who had cesarean delivery from the first pregnancy up to 8 years after the first delivery. These differences were already recognizable before the first delivery.

Pelvic organ prolapse (POP) is defined as the coexistence of anatomical POP and relevant symptoms. Vaginal bulge is the symptom most closely associated with the anatomical condition in nonpregnant women. Even if childbearing is a major risk factor for the development of POP, there is scant knowledge on the prevalence of specific POP symptoms, and how these symptoms relate to anatomical POP during pregnancy and postpartum. The aim of this study was to explore whether vaginal bulge symptoms were associated with anatomical POP in pregnancy and postpartum, and to present the prevalence of vaginal bulge symptoms throughout this period. A prospective observational study was carried out following 300 nulliparous pregnant women with repeat assessments from mid-pregnancy until 1 year postpartum. Symptoms of vaginal bulge defined as the sensation of a vaginal bulge inside and/or outside the vagina were assessed by electronic questionnaires. Anatomical POP defined as pelvic organ prolapse quantification system (POP-Q) stage ≥2 has been presented in a previous publication and showed a range of 1–9%. The association between the symptom vaginal bulge and anatomical POP at the various visits was analyzed using Fisher’s exact test. Prevalence of vaginal bulge ranged between 16 and 23%. At 6 weeks postpartum the symptom was associated with anatomical POP; otherwise, these two features were unrelated. The symptom vaginal bulge was barely associated with anatomical POP, and cannot identify anatomical POP in pregnancy or postpartum.

Introduction Symptoms related to sexual dysfunction postpartum are scarcely addressed in the literature, and the relationship to pelvic floor muscle (PFM) function is largely unknown. Aims The aim of this study was to investigate primiparous women 12 months postpartum and study: (i) prevalence and bother of coital incontinence, vaginal symptoms, and sexual matters; and (ii) whether coital incontinence and vaginal symptoms were associated with vaginal resting pressure (VRP), PFM strength, and endurance. Methods International Consultation on Incontinence Modular Questionnaire (ICIQ) sexual matters module and ICIQ-Vaginal Symptoms Questionnaire were used for questions on coital incontinence, vaginal symptoms, and sexual matters, respectively. PFM function was assessed by manometer (Camtech AS, Sandvika, Norway). Main Outcome Measures Coital incontinence, vaginal symptoms, and PFM function were the main outcome measures. Results One hundred seventy-seven primiparous women, mean age 28.7 (standard deviation [SD] 4.3) participated. Of the 94% of women having sexual intercourse, coital incontinence was found for 1.2% whereas 34.5% reported at least one vaginal symptom interfering with the sexual life of primiparous women. Of the symptoms investigated, “vagina feels dry,” “vagina feels sore,” and “vagina feels loose or lax” were most prevalent, but the overall impact on the woman's sexual life was minimally bothersome, mean 1.4 out of 10 (SD 2.5). Women reporting “vagina feels loose or lax” had lower VRP, PFM strength, and endurance when compared with women without the symptom. Conclusions Twelve-month postpartum coital incontinence was rare, whereas the prevalence of vaginal symptoms interfering with sexual life was more common. The large majority of primiparous women in our study had sexual intercourse at 12 months postpartum and the reported overall bother on sexual life was low. Women reporting “vagina feels loose or lax” had lower VRP, PFM strength, and endurance when compared with women without the symptom.

To study postpartum changes in pelvic floor morphology in a cohort of primiparous women.Transperineal ultrasound measurements taken at five examination points, both prepartum and postpartum, provided data for comparison. Three hundred nulliparous pregnant women were examined at 21 weeks of gestation and 274 (91%) at 37 weeks of gestation. At 6 weeks postpartum, 285 (95%) women were examined, 198 (66%) at 6 months, and 178 (59%) at 12 months using transperineal ultrasonography at rest, during contraction, and during Valsalva maneuver. The levator hiatus area, bladder neck mobility, and rest-to-Valsalva hiatal area difference were assessed.Approximately 85% had vaginal and 15% had cesarean deliveries. Demographic characteristics of the patients lost to follow-up were similar to the patients not lost to follow-up. In the vaginal group, a significant decrease in all measurements was seen during the first 6 months postpartum, being most pronounced for the levator hiatus area during Valsalva maneuver (-3.5 cm; P.001). In the cesarean delivery group, no significant changes between examination points were found postpartum. Only the vaginal delivery group showed significant increases in all measurements when comparing the status at 12 months postpartum with 21 weeks of gestation, most pronounced for levator hiatus area during Valsalva maneuver (3 cm; P.001). However, comparing the two delivery groups at 12 months postpartum, the only significant difference found was levator hiatus area during contraction.The levator ani muscle has the ability to recover after pregnancy and delivery, although not all women recover to pregnancy level. Most of the recovery occurs during the first 6 months postpartum. Significant pregnancy-induced changes are not shown to persist 1 year postpartum.: II.

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Objective: Identify risk factors for postpartum anatomic pelvic organ prolapse (aPOP) by comparing women with and without aPOP at six weeks postpartum with respect to pelvic floor measurements antepartum and obstetrical characteristics. Design: Prospective observational cohort study including nulliparous pregnant women Setting: Norwegian university hospital Methods: Participants underwent clinical examinations including pelvic organ prolapse quantification system (POP-Q) and transperineal ultrasound at gestational week 21 and at six weeks postpartum. Background and obstetrical information was obtained from an electronic questionnaire and from the patient’s electronic medical file, respectively. Associations were estimated using logistic regression analyses. Main outcome measures: The dependent variable was aPOP defined as POP-Q stage ≥ 2 at six weeks postpartum. Independent variables were mid pregnancy measurements of selected POP-Q variables and levator hiatus area (LHarea), delivery route, and the presence of major levator ani muscle (LAM) injuries at six weeks postpartum. Results: A larger LHarea, a more distensible LAM, a longer distance from the meatus urethra to anus (Gh+Pb) and a more caudal position of the anterior vaginal wall (Ba) at mid pregnancy were risk factors for aPOP at six weeks postpartum, while delivery route and presence of major LAM injuries were not. Conclusion: Prelabour differences in the pelvic floor rather than obstetrical events were risk factors for aPOP at six weeks postpartum. The study has been funded by the South-Eastern Norway Regional Health Authority and by the Research Council of Norway.

Background It has been suggested that women who are regular exercisers have a tighter pelvic floor and thereby have more difficulty during childbirth than non-exercising women. We investigated whether women exercising before and during pregnancy have a narrower levator hiatus (LH) area than their sedentary counterparts. We also studied whether regular exercise at gestational week 37 influences delivery outcome. Methods Cohort study of 274 nulliparous pregnant women assessed at mid-pregnancy and gestational week 37 by three-dimensional/four-dimensional transperineal ultrasonography of the LH area. Exercisers were defined as those exercising ≥30 min three times per week and non-exercisers as not exercising. Exercise data were collected via electronic questionnaire at mean gestational weeks 21 and 37. Labour and delivery outcomes were collected from the women9s electronic medical birth records. Differences between exercisers and non-exercisers were analysed using independent sample t test or χ 2 test. p Value was set to ≤0.05. Results At gestational week 37, exercisers had a significantly larger LH area than non-exercisers at rest and during PFM contraction (mean difference −1.6 cm 2 (95% CI −3.0 to −0.3), p=0.02 and −1.1 cm 2 (95% CI −2.0 to −0.1), p=0.04, respectively). No significant differences were found between exercisers and non-exercisers at week 37 in any labour or delivery outcomes. Conclusions The results of the present study do not support the hypothesis that women exercising regularly before or during pregnancy have a narrower LH area or more complicated childbirths than non-exercising women. Trial registration number ClinicalTrials.gov: NCT01045135.

Objective To investigate ability to contract, vaginal resting pressure (VRP), pelvic floor muscle (PFM) strength and PFM endurance 6 weeks after vaginal delivery in primiparous women, with and without major defects of the levator ani (LA) muscle. Design Cross-sectional comparative study. Setting Akershus University Hospital, Norway. Sample A cohort of 175 singleton primiparous women delivering vaginally after more than 32 weeks of gestation. Methods Major LA defects were assessed by 3D/4D transperineal ultrasound at maximal PFM contraction, using tomographic imaging. VRP, PFM strength and PFM endurance were measured vaginally by manometer. Data were analysed by independent-samples Student's t test, chi-square test, and standard multiple and simple linear regression. Main outcome measures VRP, PFM strength and PFM endurance. Results Of the women included in the study, 4% were not able to contract their PFM 6 weeks after delivery. Women with major LA defects (n = 55) had 47% lower PFM strength and 47% lower endurance when compared with women without major LA defects (n = 120). Mean differences were 7.5 cmH2O (95% CI 5.1–9.9, P

Theoretically, tight or strong pelvic floor muscles may impair the progress of labor and lead to instrumental deliveries. We aimed to investigate whether vaginal resting pressure, pelvic floor muscle strength, or endurance at midpregnancy affect delivery outcome.This was a prospective cohort study of women giving birth at a university hospital. Vaginal resting pressure, pelvic floor muscle strength, and endurance in 300 nulliparous pregnant women were assessed at mean gestational week 20.8 (±1.4) using a high precision pressure transducer connected to a vaginal balloon. Delivery outcome measures [acute cesarean section, prolonged second stage of labor (2 h), instrumental vaginal delivery (vacuum and forceps), episiotomy, and third- and fourth-degree perineal tear) were retrieved from the hospital's electronic birth records.Twenty-three women were lost to follow-up, mostly because they gave birth at another hospital. Women with prolonged second stage had significantly higher resting pressure than women with second stage less than 2 h; the mean difference was 4.4 cmH2O [95 %confidence interval (CI) 1.2-7.6], p0.01, adjusted odds ratio 1.049 (95 % CI 1.011-1.089, p = 0.012). Vaginal resting pressure did not affect other delivery outcomes. Pelvic floor muscle strength and endurance similarly were not associated with any delivery outcomes.While midpregnancy vaginal resting pressure is associated with prolonged second stage of labor, neither vaginal resting pressure nor pelvic floor muscle strength or endurance are associated with operative delivery or perineal tears. Strong pelvic floor muscles are not disadvantageous for vaginal delivery.

Objectives To evaluate the learning process for acquiring three- and four-dimensional (3D/4D) transperineal ultrasound volumes of the levator hiatus (LH) dimensions at rest, during pelvic floor muscle (PFM) contraction and on Valsalva maneuver, and for analyzing the ultrasound volumes, as well as to perform an interobserver reliability study between two independent ultrasound examiners. Methods This was a prospective study including 22 women. We monitored the learning process of an inexperienced examiner (IE) performing 3D/4D transperineal ultrasonography and analyzing the volumes. The examination included acquiring volumes during three PFM contractions and three Valsalva maneuvers. LH dimensions were determined in the axial plane. The learning process was documented by estimating agreement between the IE and an experienced examiner (E) using the intraclass correlation coefficient. Agreement was calculated in blocks of 10 ultrasound examinations and analyzed volumes. After the learning process was complete the interobserver reliability for the technique was calculated between these two independent examiners. Results For offline analysis of the first 10 ultrasound volumes obtained by E, good to very good agreement between E and IE was achieved for all LH measurements except for the left and right levator–urethra gap and pubic arc. For the next 10 analyzed volumes, agreement improved for all LH measurements. Volumes that had been obtained by IE and E were then re-evaluated by IE, and good to very good agreement was found for all LH measurements indicating consistency in volume acquisition. The interobserver reliability study showed excellent ICC values (ICC, 0.81–0.97) for all LH measurements except the pubic arc (ICC = 0.67). Conclusion 3D/4D transperineal ultrasound is a reliable technique that can be learned in a short period of time. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Aim To evaluate intra- and inter-rater reliability when diagnosing major defects, and inter-rater reliability of diagnosing minor defects and muscle thickness of the pubovisceral muscle in primiparous women 6 weeks after vaginal delivery, using 3D/4D transperineal ultrasound. Methods Forty primiparous women were assessed using 3D/4D transperineal ultrasound. Volumes were acquired at maximal pelvic floor muscle (PFM) contraction, and diagnosis of muscle defects were done using tomographic ultrasound imaging (TUI) of the axial plane. Thickness was measured in three central levels of TUI. The stored volumes were analyzed offline by two investigators blinded to each others' results and the women's clinical data. Cohen's kappa (κ) and percentual agreement were calculated for defects, intraclass correlations coefficient (ICC) with 95% confidence intervals were calculated for thickness. Results Excellent intra-rater values were found for all major defects. Inter-rater values for bilateral and right-sided defects were excellent, and good for left-sided. Agreement for minor defects was poor. Measuring thickness ICC of 0.72 was found for the left side and 0.48 for the right side, although up to half of the cases had to be excluded owing to poor demarcation of the muscle. Conclusion Tomographic ultrasound imaging of the axial plane using three central slices seems to be a reliable tool for detecting major pubovisceral muscle defects shortly after childbirth. Minor defects showed low reliability. Muscle thickness measurements showed moderate reliability, but too many cases had to be excluded for this to be a useful method for determining muscle thinning 6 weeks after delivery.

Objective Evaluate effect of pelvic floor muscle training (PFMT) on vaginal symptoms and sexual matters, dyspareunia and coital incontinence in primiparous women stratified by major or no defects of the levator ani muscle. Design Randomised controlled trial (RCT). Setting Akershus University Hospital, Norway. Sample About 175 primiparous women with a singleton vaginal delivery. Methods Two-armed assessor blinded parallel group RCT from 6 weeks to 6 months postpartum comparing effect of PFMT versus control. Main outcome measures International Consultation on Incontinence Modular Questionnaire—vaginal symptoms questionnaire (ICIQ-VS) and ICIQ sexual matters module (ICIQ-FLUTSsex). Results Overall, analysis (n = 175) showed no difference between training and control groups in women having vaginal symptoms or symptoms related to sexual dysfunction 6 months postpartum. The majority of women (88%) had intercourse and there was no difference between groups. Unadjusted subgroup analysis of women with a major defect of the levator ani muscle (n = 55) showed that women in the training group had 45% less risk of having the symptom ‘vagina feels loose or lax’ compared with the control group (relative risk 0.55, 95% confidence interval 0.31, 0.95; P = 0.03). Conclusions Unadjusted analysis showed that in women with major defect of the levator ani muscle, significantly fewer in the training group had the symptom ‘vagina feels loose or lax’ compared with the control group. No difference was found between groups for symptoms related to sexual dysfunction. More studies are needed to explore effect of PFMT on vaginal symptoms and sexual dysfunction. Tweetable abstract Unadjusted analysis shows that PFMT might prevent symptoms of ‘vagina feels loose or lax’.

Objective To describe changes in pelvic organ support from mid pregnancy until 1 year postpartum among nulliparous pregnant women, and to examine whether delivery route affects changes in pelvic organ support. Design Prospective cohort study. Setting Akershus University Hospital in Norway. Population A cohort of 300 nulliparous pregnant women included at mid-pregnancy. Methods Pelvic organ support assessed at 21 and 37 weeks of gestation, and again at 6 weeks, 6 months, and 12 months postpartum, by the use of the Pelvic Organ Prolapse Quantification (POP-Q) system. Linear mixed model was used to assess longitudinal change in pelvic organ support. Main outcome measures Prevalence of anatomic POP. Change in POP-Q variables over time and between delivery groups. Results The prevalence of anatomic POP ranged from 0 to 10%. Vaginal POP-Q points made a cranial shift from mid to late pregnancy, a caudal shift following delivery, and again a cranial shift after 6 weeks postpartum. Postpartum change was present following both vaginal and caesarean deliveries, but was more pronounced following vaginal delivery. The perineal body and genital hiatus became longer from mid to late pregnancy, and shortened after 6 weeks postpartum. At 12 months postpartum all POP-Q points, except cervix, had recovered to baseline in the vaginal delivery group. Conclusions The prevalence of anatomic POP was low in this cohort. There was change in pelvic organ support both during pregnancy and following vaginal as well as caesarean delivery. The short-term ability to recover was good after the first pregnancy and delivery. Tweetable abstract Pelvic organ support changes during pregnancy. A contribution to the risk of POP?

Objective To investigate associations between levator hiatus area and levator ani muscle function during pregnancy and major levator ani muscle defects postpartum. Design Observational prospective cohort study. Setting University hospital, Norway. Sample A cohort of 234 nulliparous women at 21 and 37 weeks of gestation, and at 6 weeks postpartum. Methods Ultrasound measurements of the levator hiatus at rest, during pelvic floor muscle contraction, and during the Valsalva manoeuvre were taken at 21 and 37 weeks of gestation. Levator ani muscle function was estimated as the percentage changes in levator ani muscle length from rest to contraction, and the level of muscle stretch during the Valsalva manoeuvre. Major levator ani muscle defects were diagnosed at 6 weeks postpartum using tomographic ultrasound imaging. Main outcome measures Associations between ultrasound measurements antepartum and major levator ani muscle defects postpartum. Results Women with major levator ani muscle defects postpartum had significantly smaller levator hiatus area at rest and during the Valsalva manoeuvre at mid-pregnancy (mean difference 1.03 cm2, 95% CI 0.31–1.76; 2.92 cm2, 95% CI 1.77–4.07), and at 37 weeks of gestation (mean difference 1.47 cm2, 95% CI 0.62–2.32; 2.84 cm2, 95% CI 0.88–4.80), than women without such defects. They also had significantly less shortening of the levator ani muscle during contraction at 37 weeks of gestation. Conclusions Smaller levator hiatus area at rest and during the Valsalva manoeuvre at mid and late pregnancy, and less shortening of the levator ani muscle during contraction at 37 weeks of gestation, are associated with major levator ani muscle defects postpartum.

Objective Pelvic organ prolapse (POP) is a common and distressing condition. The aim of the present study was to evaluate the effect of pelvic floor muscle training (PFMT) on prevention and treatment of symptoms and signs of POP in primiparous postpartum women. Study Design This was a parallel group assessor blind randomized controlled trial. One hundred seventy-five primiparous postpartum women, mean age 29.8 years (standard deviation 4.1), stratified on major levator ani defects or no defect diagnosed by 3-/4-dimensional ultrasound, participated in a 4-month PFMT starting at 6-8 weeks’ postpartum or control. All participants had thorough individual instruction and assessment of ability to perform correct pelvic floor muscle contractions. The PFMT group followed a supervised, weekly group training program and performed 3 sets of 8-12 daily maximal contractions at home. Main outcome was POP stage II or greater assessed by POP quantification and bladder neck position assessed by 3-/4- dimensional transperineal ultrasonography. Secondary outcome was symptoms of vaginal bulge using International Consultation on Incontinence Vaginal Symptoms questionnaire. Results Ninety-six percent of the intervention group adhered to ≥80% of both group and home training sessions. At postintervention, there was no significant risk difference in POP (rational ratio, 1.62; 95% confidence interval, 0.55–4.75), bladder neck position or symptoms of vaginal bulging. Conclusion No effect was found of postpartum PFMT on POP in primiparous women. More randomized controlled trials are needed before strong conclusions can be drawn on the effect of PFMT on POP in the particular population.

The aims of the present study were to investigate the correlation among vaginal resting pressure and pelvic floor muscle (PFM) strength and endurance, and the correlation between the same variables and levator hiatus (LH) dimensions in nulliparous pregnant women.This was a cross-sectional study of 300 nulliparous pregnant women, mean age 28.7 years (SD 4.3) and pre-pregnancy BMI 23.9 kg/m(2) (SD 3.9), assessed at mean gestational week 20.8 (±1.4). Vaginal resting pressure and PFM strength and endurance were measured using a high precision pressure transducer connected to a vaginal balloon. LH dimensions (transverse and anterior-posterior diameters_ and LH area were assessed using 3/4D transperineal ultrasound in the axial plane of minimal hiatal dimensions using render mode. The Pearson correlation was used to analyze correlations among vaginal resting pressure and PFM strength and endurance, and between PFM variables and LH dimensions. Level of significance was set at 0.05.Pelvic floor muscle strength and vaginal resting pressure were significantly, but weakly correlated (r = 0.198, p 0.001). PFM strength and endurance showed a strong correlation (r = 0.929, p 0.001). High vaginal resting pressure was moderately correlated with a small LH area at rest (r = -0.451, p 0.001), but there was no significant correlation neither between PFM strength and LH area at rest (r = -0.012, p = 0.84) nor between muscle endurance and LH area at rest (r = -0.014, p = 0.81). A strong PFM contraction correlated moderately with reduction of the LH area (r = -0.367, p 0.001).Pelvic floor muscle strength and endurance are strongly correlated, butdo not correlate with a smaller LH area at rest.

To evaluate whether postpartum pelvic floor muscle training decrease prevalence of any urinary incontinence (UI) in primiparous women with and without UI at inclusion (mixed population) and further to perform stratified analyses on women with and without major levator ani muscle defects.A two-armed assessor-blinded randomized controlled trial including primiparous women 6 weeks after vaginal delivery was conducted. Participants were stratified on major levator ani muscle defects, verified by transperineal ultrasonography, and thereafter randomly allocated to training or control. All participants were taught to contract the pelvic floor muscles. The control participants received no further intervention, whereas training participants attended a weekly supervised pelvic floor muscle training class and performed daily home exercise for 16 weeks. Primary outcome was self-reported UI analyzed by relative risk.We included 175 women, 55 with major levator ani muscle defects and 120 without. Prevalence of UI at baseline was 39.1% in the training group (n=87) and 50% among those in the control group (n=88). Fifteen women (8.6%) were lost to follow-up. At 6 months after delivery (postintervention), 34.5% and 38.6% reported UI in the training and control groups, respectively. Relative risk analysis of UI gave a nonsignificant effect size of 0.89 (95% confidence interval [CI] 0.60-1.32). Results were similar for the stratum with and without major levator ani muscle defects, 0.89 (95% CI 0.51-1.56) and 0.90 (95% CI 0.53-1.52), respectively.Postpartum pelvic floor training did not decrease UI prevalence 6 months after delivery in primiparous women. Stratified analysis on women with and without major levator ani muscle defects showed similar nonsignificant results.ClinicalTrials.gov, www.clinicaltrials.gov, NCT01069484.: I.

Objective To investigate whether pregnancy affects levator hiatus dimensions and the position and mobility of the bladder neck and the levator ani muscle in nulliparous pregnant women. Methods In the present study, 274 nulliparous pregnant women were examined at 21 weeks and 37 weeks of gestation using three-dimensional and four-dimensional transperineal ultrasonography at rest, during contraction, and during Valsalva maneuver. Levator hiatus dimensions were the anteroposterior diameter, the transverse diameter, and the area measured in rendered images. Positions of the bladder neck and levator plate were analyzed in the midsagittal plane, and mobility was calculated as displacement of the bladder neck or levator plate from rest to contraction or from rest to Valsalva. Results A significant increase for all levator hiatus dimension measurements was found from 21 weeks to 37 weeks of gestation. The most marked change was found for levator hiatus area at rest and during Valsalva maneuver, in which the mean area was increased by 17.1% (11.7-13.7 cm(2)) and 21.4% (15.4-18.7 cm(2)), respectively. Bladder neck mobility changed significantly during pregnancy. The most marked change was seen from rest to contraction (mean -14 mm, standard deviation 0.4). Conclusions An increase of all hiatal dimensions as well as bladder neck mobility was found from 21 weeks to 37 weeks of gestation in nulliparous pregnant women. The findings indicate that the changes in pelvic organ support are not solely caused by delivery, but also by physiologic changes during pregnancy. Level of evidence II.

To evaluate intra- and inter-rater reliability when diagnosing major defects, and inter-rater reliability of diagnosing minor defects and muscle thickness of the pubovisceral muscle in primiparous women 6 weeks after vaginal delivery, using 3D/4D transperineal ultrasound.Forty primiparous women were assessed using 3D/4D transperineal ultrasound. Volumes were acquired at maximal pelvic floor muscle (PFM) contraction, and diagnosis of muscle defects were done using tomographic ultrasound imaging (TUI) of the axial plane. Thickness was measured in three central levels of TUI. The stored volumes were analyzed offline by two investigators blinded to each others' results and the women's clinical data. Cohen's kappa (κ) and percentual agreement were calculated for defects, intraclass correlations coefficient (ICC) with 95% confidence intervals were calculated for thickness.Excellent intra-rater values were found for all major defects. Inter-rater values for bilateral and right-sided defects were excellent, and good for left-sided. Agreement for minor defects was poor. Measuring thickness ICC of 0.72 was found for the left side and 0.48 for the right side, although up to half of the cases had to be excluded owing to poor demarcation of the muscle.Tomographic ultrasound imaging of the axial plane using three central slices seems to be a reliable tool for detecting major pubovisceral muscle defects shortly after childbirth. Minor defects showed low reliability. Muscle thickness measurements showed moderate reliability, but too many cases had to be excluded for this to be a useful method for determining muscle thinning 6 weeks after delivery.

The objectives of the investigation were to study the association between levator hiatus dimensions in late pregnancy and both the length of second stage of labor and also the delivery mode in women delivering their first child.In this cohort study, 231 nulliparous women were examined with 3- and 4-dimensional transperineal ultrasonography at 37 weeks of gestation. The anteroposterior, transverse diameter, and the area of levator hiatus were measured at rest, during levator ani muscle contraction, and during Valsalva maneuver. The second stage of labor was divided into passive and active second stage and delivery modes into normal vaginal or instrumental deliveries. Spearman correlation coefficient, independent-sample t test, and standard logistic regression were used for analysis.Larger levator hiatus dimensions at rest and during contraction at 37 weeks of gestation correlated with a shorter duration of the active second stage in women with normal vaginal delivery (Spearman correlation coefficient, -0.13 to -0.35, P ≤ .08). Women having normal vaginal deliveries had significantly larger transverse diameter at rest, during contraction, and during Valsalva maneuver compared with women having instrumental deliveries (mean difference, 0.29; 95% confidence interval (CI), 0.16-0.41; mean difference, 0.33; 95% CI, 0.21-0.44 and mean difference, 0.24; 95% CI, 0.06-0.42; P.05). The same was true for the levator hiatus area at rest and during contraction (mean difference, 1.22; 95% CI, 0.37-2.07 and mean difference, 0.84; 95% CI, 0.22-1.46; P.01). These estimates were unchanged by adjustments in the logistic regression analysis.Larger levator hiatus dimensions in late pregnancy had a significant association with a shorter active second stage of labor and normal vaginal delivery.

We sought to study impact of delivery mode on vaginal resting pressure (VRP) and on pelvic floor muscle (PFM) strength and endurance, and whether these measurements differed in women with and without urinary incontinence.We conducted a cohort study following 277 nulliparous women from midpregnancy to 6 weeks postpartum. Manometer was used for PFM measurements; differences were analyzed by t test (within groups) and analysis of variance (between groups).Only VRP changed significantly (10% reduction, P = .001) after emergency cesarean section. After normal and instrumental vaginal delivery, VRP was reduced by 29% and 30%; PFM strength by 54% and 66%; and endurance by 53% and 65%, respectively. Significant differences for all PFM measures (P.001) were found when comparing cesarean vs normal and instrumental vaginal delivery, respectively. Urinary continent women at both time points had significantly higher PFM strength and endurance than incontinent counterparts (P.05).Pronounced reductions in VRP and in PFM strength and endurance were found after vaginal delivery. Continent women were stronger than incontinent counterparts.