Childbirth and the Pelvic Floor by Biscuit350

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									The problem
with human
childbirth: A
large object
must pass
through a
channel with
both the object
and the channel
And this, he said, is the reason why the cure of many diseases
is unknown to the physicians of Hellas, because they
disregard the whole, which ought to be studied also; for the
part can never be well unless the whole is well.
Pelvic floor Damage/dysfunction:

   Vaginal delivery
   Pregnancy itself
   Aging
   Estrogen deficiency
   Neurological disease
       Compounding Problems:

   Embarrassment leads to silence
   Time constraints lead to inadequate
   Knowledge limits lead to patient
    acceptance (changing)
   Technology limits lead to inadequate
    investigation (especially rural areas)
   Resource limits lead to inadequate
   First world women are more active
   Increasingly less willing to accept these
   Incontinence can destroy sport/recreation/job
   Culture of litigation (Western world). Lawsuits
    related to pelvic floor just a matter of time
   Outcast 3rd world women
   10-60% of women report urinary
   Objective studies - lower prevalence
   50% of women that have had children
    develop prolapse
   Only 10-20% seek medical care
   Billions of dollars spent annually on
    incontinence products (in North

   10-25% of women age 15-64 report
    urinary incontinence
   15-40% of women over age 60 in the
    community report incontinence
   More than 50% of women in nursing
    homes are incontinent
   W.H.O. recognizes incontinence as an
    international health concern
   Anal incontinence is the current greater
    “pelvic floor closet issue”
   Incidence and prevalence figures vary
   Approximately 10% or more women
    with urinary incontinence have
    incontinence of flatus or stool
   Only 39% of anal incontinence after
    delivery cleared in 10 months (MacArthur C,et
    al: BR J Obstet Gynaecol 104:46-50,1997)
        Quality of Life Impact:

   Impact on lifestyle and avoidance of
   Fear of losing bladder control
   Embarrassment
   Impact on relationships/sexual
   Increased dependence on caregivers
   Discomfort and skin irritation
        Demographics: (first world:)
   Aging baby boomers
   Increased percentage of older people
   Percentage of life after reproductive age the
    most in human history
   Percentage of life spent being pregnant the
    lowest in history
   Most Western countries have low and
    dropping fecundity (Canada: 1.5)
   Italy: now 60 million; 3000 – 20 million
   Trend to having children later
    Prof Bruno Lunenfeld: Andrology in the Nineties International Symposium on Human Sub-
    Fertility. 24 March 1999 Cape Town, South Africa

   Gravity
   Neurologic changes with aging
   Loss of estrogen
   Changes in connective tissue
    crosslinking and reduced elasticity
   Frequency
   Nocturia
   Dysuria
   Incomplete emptying
   Incontinence
   Urgency
   Recurrent infections
   Dyspareunia
   Prolapse
           Hormone Effects:
   Common embryonic origin of bladder
    urethra and vagina from urogenital
   High concentration of estrogen
    receptors in tissues of pelvic support
   General collagen deficiency state in
    postmenopausal women due to the lack
    of estrogen
   Urethral coaptation affected by loss of
   However; HRT not very effective!
      Increased Intra-abdominal
   Pulmonary disease
   Constipation/straining
   Lifting
   Exercise
   Ascites/hepatomegaly
   Obesity
      Pregnancy and Childbirth:

   Hormonal effects in pregnancy
   Pressure of uterus and contents
   Denervation (stretch or crush injury to
    pudendal nerve)
   Connective tissue changes or injury
   Mechanical disruption of muscles and
                    C/S vs Vaginal:
   OR for Vaginal delivery and stress
    incontinence: 11
   RR of parity for prolapse: 10.85
   Rectal sphincter complex damaged in
    35 - 80% of first vag births (endoanal
   Most damage in first birth
   Cumulative damage in later births

    *Tetzschner et al. Acta Obstet Gynecol Scan 1997; 76: 324
                    Risk factors:
   Big baby
   Long labour/second stage
   Forceps (vacuum protective?)
   Episiotomy?
   Elective (not emergency) C/S protective for
    anal incontinence

    (Sultan AH et al: N Engl J Med 329:1905-1911, 1993
                      BMJ 308:887-891, 1994)
    (MacArthur C,et al: BR J Obstet Gynaecol 104:46-50,1997)
         Risk of C/S vs Vaginal:
   Nonelective C/S rate > 27% might yield
    higher maternal mortality than universal
    elective C/S
   Universal C/S - extra 1/18000 maternal
   36 to 360 fetuses saved for each
    maternal mortality related to elective
    C/S. (1/50 - 1/500 fetuses suffer
    disaster in utero after maturity)
    Feldman G.B, Freiman J.A; N Engl J Med 312, 1264-1267
            Risk of Cesarean birth:
   Little data on purely elective C/S in
    healthy women
   Data usually include all C/S
   Sweden 1973-79: Mortality rate:
    emerg C/S: 0.18/1000
    elective C/S: 0.04/1000 (5:1) Other
    studies suggest smaller difference
   Risk C/S:vaginal 5:1 (not only elective!)
   We can probably do even better
    (heparin, universal A/B profilaxis etc.)
    Lilford R,J et al; Br J Obstet 1990; 97:883-892
     Cost of C/S vs vaginal birth:

   Depends on society (medical system)
   No level playing field in studies;
    all C/S usually lumped together
   Later prolapse/incontinence related
    costs, direct & indirect, not included
   Thus: most data biased
           Surgery statistics (US):

   Ratio of surgery for prolapse vs incontinence:
   Lifetime risk of surgery for prolapse: 11.1%
   Estimated re-operative rate: 29%
   1/2 million prolapse surgeries /year (US)
   2030 estimation: 7 mil/y + 2 mil reoperations

    (Bump R, Norton P: OB/Gyn Clinics 25, # 4, Dec. 1998)
    (Mailet VT et al: Presentation to AUGS, Sep 1997)
             Informed concent:
   Culturally based
   Difficult and time consuming
   NOT appropriate in labour
   Taking into consideration fertility wishes
    and age (eg. # of children wished)
    (37yo wanting 1; vs 20yo wanting 4)
   Full discussion of relative risks,
   Financial/resource issues -
              It is a dimension
           It is a quantum wave
           It is a vibrating string

Whatever it is, we don’t have enough!
Elective cesarean birth for some
“On the basis of current available evidence,
the concept of an elective prophylactic
cesarean section being outrageous, has been
shattered by the fact that almost a third of
female obstetricians would choose it for

Paterson-Brown S; Queen Charlotte’s and Chelsea Hospital,
Lancet 1996,347:544
                     Future issues:

   Risk prediction models (like in maternal-
    fetal medicine and oncology)
   Computer technology/neural network
   Cooperative efforts:
    (Check structural integrity of the whole building, not only one
            Future research:

   MRI pelvimetry (new fast scan
   Collagen/DNA/muscle studies
   Nerve studies
   Age
   Family history
   Number of children planned
of pelvic floor dysfunction:
ICS standardized prolapse system
 Anterior wall     Anterior wall    Cervix or cuff
      Aa               Ba                 C

Genital hiatus                        Total vaginal
                  Perineal body
     gh                pb

 Posterior wall    Posterior wall     Posterior
      Ap                Bp
   Contrast radiography: (voiding
   MRI, CT: (not dynamic, and supine)
   Ultrasound: (not very practical)
   Testing of pelvic floor muscles:
    (inspection, palpation, EMG, pressures)
Non-surgical Treatment:

 Pelvic floor exercises

 Vaginal cones

 Devices for reinforcement
Surgical Treatment

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