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To tear and to heal: pelvic floor dysfunction and childbirth
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Kvinnokliniken Östersund.
2023 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Att brista och att läka : bäckenbotten efter förlossning (Swedish)
Abstract [en]

Background: Up to 80% of women are affected by a perineal laceration after their first vaginal birth. An estimated 40–50% of lacerations involve the perineal muscles, and up to 7% are obstetric anal sphincter injuries (OASI). There is a lack of knowledge about the extent of short-term complications such as pelvic floor dysfunction (PFD) following spontaneous or iatrogenic pelvic floor trauma. Women’s experiences of daily life after childbirth complicated by OASI is poorly understood. Three-dimensional endoanal ultrasonography (3D-EAUS) is a welldocumented method for evaluating damage to the anal sphincter in other contexts. Adding ultrasonography to standard clinical examination has revealed injuries previously missed, and research evaluating diagnostic methods for the routine screening of OASI has been called for.

Aim: This thesis aims to evaluate the diagnostics of OASI, determine if the degree of perineal injury or anal sphincter defects after childbirth are associated with pelvic dysfunction, and explore women’s experiences of OASI.Methods Studies I and IV were prospective cohort-studies to evaluate any association between perineal tear or sphincter defect to PFD. Study II was an interview study addressing women’s experiences of OASI by qualitative content analysis. Study III was a cross-sectional study designed to examine the utility of endoanal ultrasound to detect OASI. Participants were clinically examined after birth and 3D-EAUS was performed immediately after giving birth and 3 months postpartum. PFD was evaluated using a web-based questionnaire one year after delivery.

Results: A total of 511 women completed the one-year questionnaire (Study I) and a purposive sample of 11 women were invited to take part in Study II. In Study III, 680 women underwent a clinical examination and 3D-EAUS recording immediately after birth. In Study IV, 239 women who attended all follow-ups were included. PFD was experienced by women with a perineal laceration of any grade, but also those with an intact perineum. Dyspareunia and urinary incontinence were the most common problems. Women with OASI had a higher risk for developing vi symptoms of prolapse, urinary urge incontinence, dyspareunia, and pain as well as experiencing a negative impact on their daily life. Elements that negatively influenced women’s experiences of OASI were pain and symptoms of PFD, normalisation of symptoms by healthcare providers, and unrealistic expectations about this period in life. 3D-EAUS immediately after delivery had poor sensitivity and specificity in detecting clinically diagnosed OASI. Postpartum anal sphincter defects were associated with genital pain and dyspareunia.

Conclusions: OASI is an evident risk factor for pelvic floor dysfunction after childbirth, but symptoms of pelvic floor disorder were found to be common, even in women with mild to moderate perineal laceration. OASI has a negative impact on how a woman experiences relationships, social contact, and sexuality. Using 3D-EAUS in a maternity ward to diagnose OASI is demanding. Staff generally have little experience in 3D-EAUS. There are also difficulties in obtaining good image quality, due to local oedema, bleeding, positioning of the woman, and unintentional movements. These factors all complicate the interpretation of images.

Place, publisher, year, edition, pages
Umeå: Umeå University , 2023. , p. 92
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2241
Keywords [en]
pelvic floor disorders, endosonography, dyspareunia, perineum, pain, qualitative research, delivery
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Medicine
Identifiers
URN: urn:nbn:se:umu:diva-206520ISBN: 978-91-7855-997-8 (print)ISBN: 978-91-7855-998-5 (electronic)OAI: oai:DiVA.org:umu-206520DiVA, id: diva2:1749586
Public defence
2023-05-05, Hörsalen, Östersunds sjukhus, Östersund, 09:00 (Swedish)
Opponent
Supervisors
Funder
Region Jämtland Härjedalen, 8176Region Jämtland Härjedalen, 8266Visare Norr, 2048Available from: 2023-04-14 Created: 2023-04-10 Last updated: 2023-04-13Bibliographically approved
List of papers
1. Pelvic floor dysfunction one year after first childbirth in relation to perineal tear severity
Open this publication in new window or tab >>Pelvic floor dysfunction one year after first childbirth in relation to perineal tear severity
2021 (English)In: Scientific Reports, E-ISSN 2045-2322, Vol. 11, no 1, article id 12560Article in journal (Refereed) Published
Abstract [en]

The aims of this study were to evaluate pelvic floor dysfunction symptoms one year after delivery and investigate whether adverse functional outcomes after childbirth were related to the degree of perineal injury. A prospective cohort of 776 primiparas were included. Self-reported pelvic floor function data were obtained using a web-based questionnaire. Women with no/first-degree injuries, second-degree injuries, third-/fourth-degree injuries (obstetric anal sphincter injury, OASI) and cesarean section were compared. A total of 511 women (66%) responded. Second-degree tears were a risk factor for stress incontinence (aOR 2.6 (95% CI 1.3–5.1)). Cesarean section was protective against stress incontinence (aOR 0.2 (95% CI 0.1–0.9)). OASI was a risk factor for urge incontinence (aOR 4.8 (95% CI 1.6–15)), prolapse (aOR 7.7 (95% CI 2.1–29)) and pelvic pain (OR 3.3 (95% CI 1.1–10)). Dyspareunia was reported by 38% of women, 63% of women in the OASI group (aOR 3.1 (95% CI 1.1–9.0)). Women with OASI reported that the injury affected daily life (OR 18 (95% CI 5.1–59)). Pelvic floor dysfunction is common after childbirth, even in women with moderate injury. Women with OASI had significantly higher risks of symptoms of prolapse, urge urinary incontinence, pain, dyspareunia and impacts on daily life.

Place, publisher, year, edition, pages
Nature Publishing Group, 2021
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-185311 (URN)10.1038/s41598-021-91799-8 (DOI)000664660000007 ()34131194 (PubMedID)2-s2.0-85108172505 (Scopus ID)
Available from: 2021-06-28 Created: 2021-06-28 Last updated: 2023-09-05Bibliographically approved
2. "From hell to healed" - A qualitative study on women's experience of recovery, relationships and sexuality after severe obstetric perineal injury
Open this publication in new window or tab >>"From hell to healed" - A qualitative study on women's experience of recovery, relationships and sexuality after severe obstetric perineal injury
2022 (English)In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 33, article id 100736Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Few studies have investigated women's experiences of daily life after childbirth complicated by obstetric anal sphincter injury (OASI). The aim of the present study was to explore experiences related to recovery, sexual function, relationships and coping strategies among women affected by OASI.

METHODS: In-depth interviews were conducted using a purposive sample of 11 women affected by OASI. Women were interviewed 1-2 years after their first childbirth. Inductive qualitative content analysis was applied.

RESULTS: The theme "From hell to healed" illustrates women's experiences of recovery, relationships and sexual function after OASI. Three categories addressing women's perceptions emerged: "Challenged to the core", "At the mercy of the care provider" and "For better or for worse". Support from partners and family and comprehensive care were important elements for the experiences of coping and healing from OASI. Elements that negatively influenced women's experiences were the pain and physical symptoms of pelvic floor dysfunction, normalization of symptoms by heath care providers, and unrealistic expectations about how this period in life should be experienced.

CONCLUSION: OASI greatly affects women's experiences of their first years with their newborn child, relationships, social context and sexuality. For some women, OASI negatively affects everyday life for a long period after childbirth. However, others heal and cope quite quickly. Health care professionals need to identify and pay attention to women with persisting problems after OASI so that they can be directed to the right level of care.

Place, publisher, year, edition, pages
Elsevier, 2022
Keywords
Experiences, Obstetric anal sphincter injury, Qualitative, Relations, Sexual function
National Category
Obstetrics, Gynecology and Reproductive Medicine Nursing
Identifiers
urn:nbn:se:umu:diva-197704 (URN)10.1016/j.srhc.2022.100736 (DOI)000807216300001 ()35640528 (PubMedID)2-s2.0-85131063310 (Scopus ID)
Available from: 2022-07-04 Created: 2022-07-04 Last updated: 2023-08-11Bibliographically approved
3. Use of endoanal ultrasound in detecting obstetric anal sphincter injury immediately after birth
Open this publication in new window or tab >>Use of endoanal ultrasound in detecting obstetric anal sphincter injury immediately after birth
Show others...
2023 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 102, no 3, p. 389-395Article in journal (Refereed) Published
Abstract [en]

Introduction: Obstetric anal sphincter injury (OASI) complicates around 5% of deliveries in primiparas. The study objective was to assess the utility of three-dimensional endoanal ultrasonography (3D-EAUS) in the diagnosis of OASI.

Material and methods: The present study was designed to mirror screening settings with an unselected cohort of nulliparous women. All enrolled patients underwent clinical examination of the perineum by the caregiver, and 3D-EAUS was conducted. Post-processing of ultrasonography volume data was performed by an experienced colorectal surgeon who was blinded to all other data. The sensitivity, specificity, negative predictive value, and positive predictive value of 3D-EAUS in the diagnosis of OASI was evaluated. The trial is registered at ISCRTN: 18006769.

Results: A total of 680 scans were performed, of which 18.5% were judged as “non-assessable”, resulting in 554 assessable recordings. Sphincter defects were observed in 12.8% of all assessable recordings on 3D-EAUS (n = 71). With clinical examination set as the reference standard, ultrasound sensitivity in the diagnosis of OASI was 30.4%, whereas its specificity was 87.9%. The negative predictive value was 96.7% and the positive predictive value was only 9.9%. Comments were left on 175 examinations, of which 74% referred to the management of the examination.

Conclusions: Using 3D-EAUS in a maternity ward is demanding because staff generally have little experience in endoanal ultrasound, which contributes to difficulties in obtaining good image quality. When 3D-EAUS is performed to mirror screening settings, it adds no convincing diagnostic power to clinical examination in the diagnosis of OASI.

Place, publisher, year, edition, pages
John Wiley & Sons, 2023
Keywords
endoanal ultrasound, feasibility, obstetric anal sphincter injury, pelvic floor, postpartum, three-dimensional endoanal ultrasonography
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-204498 (URN)10.1111/aogs.14514 (DOI)000916695700001 ()36683208 (PubMedID)2-s2.0-85147035441 (Scopus ID)
Funder
Region Jämtland Härjedalen, 8176Västerbotten County CouncilVisare Norr
Available from: 2023-02-08 Created: 2023-02-08 Last updated: 2024-04-09Bibliographically approved
4. The prevalence of postpartum anal sphincter defects and the association with perineal pain and dyspareunia
Open this publication in new window or tab >>The prevalence of postpartum anal sphincter defects and the association with perineal pain and dyspareunia
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-206584 (URN)
Available from: 2023-04-12 Created: 2023-04-12 Last updated: 2023-04-12

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