It is the first birth that does the damage: a cross-sectional study 20 years after delivery

Int Urogynecol J. 2018 Nov;29(11):1637-1643. doi: 10.1007/s00192-018-3616-4. Epub 2018 Mar 21.


Introduction and hypothesis: Levator ani muscle (LAM) and anal sphincter tears are common after vaginal birth and are associated with female pelvic organ prolapse and anal incontinence. The impact of subsequent births on LAM and external anal sphincter (EAS) integrity is less well defined. The objective of this study was to determine the prevalence of LAM and EAS trauma in primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally to assess if there were differences between the two groups. The null hypothesis was: there is no significant difference in the prevalence of LAM and EAS trauma between the two groups.

Methods: This was a cross-sectional study involving 195 women, participants of the Dunedin arm of the ProLong study (PROlapse and incontinence LONG-term research study) seen 20 years after their index birth. Assessment included a standardized questionnaire, ICS POP-Q and 4D translabial ultrasound. Post-imaging analysis of LAM and EAS integrity was undertaken blinded against other data. Statistical analysis was performed using Fisher's exact test and results were expressed as odds ratios (OR).

Results: LAM avulsion and EAS defects were diagnosed in 31 (16%) and 24 (12.4%) women respectively. No significant difference in the prevalence of levator avulsion and EAS defects between primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally (OR 1.9, 95% CI 0.72-5.01, p = 0.26) and (OR 1.2, 95% CI 0.4-3.8, p = 0.76) respectively.

Conclusions: Most LAM avulsions and EAS defects seem to be caused by the first vaginal birth. Subsequent vaginal deliveries after the first were unlikely to cause further LAM trauma.

Keywords: Anal sphincter tears; Levator ani avulsion; Pelvic floor trauma; Pelvic organ prolapse; Vaginal parity.

MeSH terms

  • Adult
  • Anal Canal / injuries*
  • Anus Diseases / epidemiology*
  • Anus Diseases / etiology
  • Birth Order
  • Cross-Sectional Studies
  • Delivery, Obstetric / adverse effects*
  • Delivery, Obstetric / methods
  • Female
  • Humans
  • Longitudinal Studies
  • Middle Aged
  • Obstetric Labor Complications / epidemiology*
  • Obstetric Labor Complications / etiology
  • Odds Ratio
  • Parity
  • Pelvic Floor / diagnostic imaging
  • Pelvic Floor Disorders / epidemiology*
  • Pelvic Floor Disorders / etiology
  • Postpartum Period
  • Pregnancy
  • Prevalence
  • Surveys and Questionnaires
  • Ultrasonography / methods
  • Vagina
  • Vulva / diagnostic imaging