Does vaginal delivery cause more damage to the pelvic floor than cesarean section as determined by 3D ultrasound evaluation? A systematic review

Int Urogynecol J. 2018 May;29(5):639-645. doi: 10.1007/s00192-018-3609-3. Epub 2018 Mar 21.


Introduction and hypothesis: Pregnancy and delivery are well-established risk factors for pelvic floor dysfunction (PFD), but the physiopathology, such as the delivery route, is not well understood. This study evaluated the impact of delivery route on the pelvic floor muscles via 3D ultrasound.

Methods: This review is registered in the PROSPERO database. The criteria for inclusion were prospective studies with 3D translabial ultrasound assessment in primigravida women during pregnancy and postpartum published in English, Spanish or Portuguese between 1980 and 2016. We excluded studies that did not include the topic of urogenital hiatus measurement and literature reviews. The MeSH terms were obstetric delivery, postpartum period, labor, parturition, three-dimensional images, ultrasonography, pelvic floor, and pelvic floor disorders.

Results: The search retrieved 155 articles. After analysis, 6 articles were included. Four studies showed that vaginal delivery (VD) was associated with a larger hiatal area. One study associated the hiatal area with levator ani muscle (LAM) defects in VD. Four articles evaluated the bladder neck, 3 of which showed a significant increase in bladder neck mobility associated with VD and 1 showed decreased bladder neck elevation, not associated with the delivery mode; the first 3 articles all evaluated LAM injuries and showed an association between VD and LAM injury. Women who underwent VD presented defects of the puborectalis muscle.

Conclusions: Vaginal delivery was associated with a higher number of LAM injuries, puborectalis defects, increased bladder neck mobility, and enlargement of the hiatal area.

Keywords: Obstetric delivery; Parturition; Pelvic floor disorders; Postpartum period; Three-dimensional images; Ultrasonography.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Anal Canal / anatomy & histology
  • Anal Canal / diagnostic imaging*
  • Anal Canal / physiopathology
  • Cesarean Section* / adverse effects
  • Delivery, Obstetric* / adverse effects
  • Female
  • Humans
  • Imaging, Three-Dimensional
  • Pelvic Floor / anatomy & histology
  • Pelvic Floor / diagnostic imaging*
  • Pelvic Floor Disorders / complications*
  • Perineum / anatomy & histology
  • Perineum / diagnostic imaging
  • Postpartum Period / physiology*
  • Pregnancy
  • Pregnancy Complications / diagnostic imaging*
  • Pregnancy Complications / physiopathology
  • Ultrasonography