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Urogynecology: Original Research

Comparison of Levator Ani Muscle Avulsion


Injury After Forceps-Assisted and
Vacuum-Assisted Vaginal Childbirth
Hafsa U. Memon, MBBS, Joan L. Blomquist, MD, Hans P. Dietz, MD, PhD, Christopher B. Pierce, MHS,
Milena M. Weinstein, MD, and Victoria L. Handa, MD, MHS

OBJECTIVE: Using three-dimensional transperineal differences between groups in maternal age at first
ultrasonography, we compared the prevalence of levator delivery, parity, body mass index, birth weight, episiot-
ani muscle injury after forceps with vacuum-assisted omy, or duration of second stage. History of anal
vaginal delivery. sphincter laceration was more common in the forceps
METHODS: This was a retrospective cohort study. group. The prevalence of levator ani muscle avulsion was
Women who experienced at least one forceps delivery significantly higher after forceps compared with vacuum
(across all deliveries) were compared with women who delivery (22/45 [49%] compared with 5/28 [18%], P5.012,
had at least one vacuum birth. On average, participants prevalence ratio 2.74, 95% confidence interval [CI] 1.17
were 10 years from the index delivery. Three- 6.40, odds ratio 4.40 [95% CI 1.4213.62]). Controlling for
dimensional transperineal ultrasound volumes were cap- delivery type, levator ani muscle avulsion was associated
tured as cine loops at rest with Valsalva and with pelvic with symptoms of prolapse (P5.036), although objective
floor muscle contraction. The primary outcome was evidence of prolapse was not significantly different
levator ani muscle avulsion. Secondary outcomes between groups (P5.20).
included hiatal diameter and area. Prevalence of pelvic CONCLUSION: Ten years after delivery, the prevalence
floor disorders was also compared between the two of levator avulsion is almost tripled after forceps com-
delivery groups. pared with vacuum-assisted vaginal delivery.
RESULTS: Among 45 participants in the forceps group (Obstet Gynecol 2015;125:10807)
and 28 participants in the vacuum group, there were no DOI: 10.1097/AOG.0000000000000825
LEVEL OF EVIDENCE: II

F
From the Department of Gynecology and Obstetrics, Johns Hopkins University,
the Department of Gynecology, Greater Baltimore Medical Center, and the
orceps-assisted vaginal delivery is associated with
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, increased prevalence of pelvic floor disorders and
Baltimore, Maryland; the Department of Obstetrics, Gynecology and Neo- a significant reduction in pelvic floor muscle
natology, Sydney Medical School Nepean, Kingswood, New South Wales,
Australia; and the Department of Obstetrics and Gynecology, Massachusetts strength.13 In contrast, vacuum-assisted vaginal deliv-
General Hospital, Harvard Medical School, Boston, Massachusetts. ery is not associated with prolapse or reduction in the
Supported by an American College of Obstetricians and Gynecologists/Kenneth strength of pelvic floor muscles when compared with
Gottesfeld-Charles Hohler Memorial Foundation grant and the Eunice Ken- spontaneous vaginal birth.3,4 The mechanism for these
nedy Shriver National Institute of Child Health and Human Development
(R01HD056275).
differential associations among the type of operative
vaginal delivery, pelvic floor disorders, and decreased
Presented as a poster at the 62nd Annual Clinical and Scientific Meeting of the
American College of Obstetricians and Gynecologists, April 2630, 2014, pelvic floor muscle strength is not clear.
Chicago, Illinois. Levator ani muscle is an important component
Corresponding author: Hafsa U. Memon, MBBS, Department of Gynecology and of pelvic floor support system and injury to this
Obstetrics, Johns Hopkins University, 4940 Eastern Avenue, 301 Building, muscle complex has been associated with pelvic floor
Baltimore, MD 21224; e-mail: hafsa.memon@gmail.com.
disorders.57 Levator ani muscle avulsion has been
Financial Disclosure
The authors did not report any potential conflicts of interest.
observed after 5065% of forceps deliveries.810 A
similar association has not been noted for vacuum
2015 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved. delivery.8 Because these two types of deliveries are
ISSN: 0029-7844/15 practiced in the setting of second-stage labor dystocia

1080 VOL. 125, NO. 5, MAY 2015 OBSTETRICS & GYNECOLOGY

Copyright by The American College of Obstetricians


and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
and to expedite delivery in certain obstetric scenar- episiotomy, spontaneous perineal laceration, and
ios, a critical question is whether the increased prev- obstetric anal sphincter laceration. Obstetric histories
alence of levator injury after forceps delivery is were abstracted from hospital charts by trained per-
related to the mode of delivery itself or is it a result sonnel and were recorded in an electronic database.
of a difficult labor. For data missing from the medical record, or for some
In this study, we investigated this important participants who delivered a subsequent child at a dif-
question by comparing the prevalence of levator ani ferent hospital, we relied on the womans reported
muscle avulsion injury after forceps compared with description of all obstetric events.
vacuum-assisted vaginal deliveries several years after Data regarding the presence or absence of pelvic
the index delivery. Such comparison is lacking from floor disorders among women who agreed to partic-
the current literature. Our second goal was to assess ipate in the ultrasound study were also extracted from
whether levator ani muscle injury, independent of the established electronic database of the Mothers
delivery type, is associated with pelvic floor disorders. Outcomes After Delivery cohort. Symptoms of pelvic
floor disorders were assessed using the validated, self-
MATERIALS AND METHODS administered Epidemiology of Prolapse and Inconti-
Participants were recruited from the Mothers nence Questionnaire, completed annually by the
Outcomes After Delivery study, an established longi- study participants.2 This questionnaire generates
tudinal cohort study investigating pelvic floor out- scores for four pelvic floor disorders: stress urinary
comes among parous women. Institutional review incontinence, overactive bladder, anal incontinence
board approval was obtained from Johns Hopkins and pelvic organ prolapse. In each case, a previously
medical institution for the parent study as well as this published validated threshold was used to define
ultrasound study. women who met criteria for each disorder, respec-
The recruitment methods for this longitudinal tively.2 Study participants also underwent annual pel-
cohort have been previously published in detail.2 At vic organ prolapse quantification examination as part
the time of this analysis, 1,371 women were enrolled of the Mothers Outcomes After Delivery study pro-
in the Mothers Outcomes After Delivery study. All tocol.2 Prolapse was defined as descent of the cervix
study participants had delivered their first child at or any vaginal segment to or beyond the hymen.2
Greater Baltimore Medical Center 515 years before Levator ani muscle avulsion was identified using
enrollment. For the study presented here, the popula- three-dimensional transperineal ultrasonography;
tion of interest was the subset with a history of forceps ultrasound acquisition and interpretation were based
or vacuum-assisted vaginal delivery. Using the estab- on published protocols.9,11 Specifically, the ultrasono-
lished electronic database of the Mothers Outcomes gram was performed with the participant in the dorsal
After Delivery study, we identified participants with lithotomy position with an empty bladder. Before
a history of either a forceps or a vacuum-assisted vag- imaging, each patient was instructed in the technique
inal birth across all childbirths. Only those women of pelvic floor muscle contraction and Valsalva. We
whose operative vaginal deliveries were confirmed used the GE Voluson 730 system with RAB 4-8L 4D
from the review of hospital records were included in convex transducer. The ultrasound transducer was
this study. Women with a history of both forceps and covered with a sheath and applied to the perineum
vacuum-assisted deliveries were excluded. We also in the midsagittal plane. Landmarks of the symphysis
excluded women who were currently pregnant and pubis and the anal canal were identified. Three-
those less than 6 months postpartum. Written dimensional ultrasound volumes were captured as
informed consent was obtained for participation in cine loops at rest, Valsalva, and pelvic floor muscle
this study. contraction and were stored on a compact disc for
Demographic data and additional obstetric histo- later analysis. All ultrasonograms were performed
ries of women who agreed to participate were by the principal investigator (H.U.M.), who was
abstracted from the established electronic database blinded to both the obstetric exposures of each par-
of the longitudinal cohort. This included maternal age ticipant, and the presence or absence of any pelvic
at first delivery and at the index delivery; maternal floor disorders.
age, parity, and body mass index (calculated as weight The ultrasound volumes were analyzed offline
(kg)/[height (m)]2) at the time of ultrasonography; race using GE 4Dview 14 Ext 0. Using this software, the
(Caucasian or non-Caucasian); any vaginal birth with ultrasound volumes were rotated and displayed in the
second stage of labor greater than 120 minutes; heavi- standard orthogonal planescoronal, sagittal, and
est vaginal birth weight in grams; and history of transverse. At the time of this evaluation, examiners

VOL. 125, NO. 5, MAY 2015 Memon et al Levator Injury After Operative Vaginal Birth 1081

Copyright by The American College of Obstetricians


and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
were masked to obstetric history and to the presence The plane of minimal hiatal dimension is defined as
or absence of pelvic floor disorders. We performed the minimal distance between the hyperechoic pos-
tomographic ultrasound imaging of the contraction terior aspect of the pubic symphysis and the hyper-
volume at 2.5-mm slice intervals, from 5 mm below echoic anterior margin of the levator ani muscle just
to 12.5 mm above the plane of minimal hiatal dimen- behind the anorectal angle in midsagittal plane.15,16
sion, producing eight slices per patient,9 as shown in The change in hiatal area from rest to pelvic floor
Figure 1A. The diagnosis of levator avulsion was muscle contraction was calculated by subtracting
made if there was evidence of discontinuity between area at pelvic floor muscle contraction from area at
the levator muscle and the inferior pubis ramus during rest. The change in hiatal area from rest to Valsalva
maximal pelvic floor contraction at the plane was calculated by subtracting area at rest from area at
of minimal hiatal dimension and for at least 5 mm Valsalva.
above that level (ie, if discontinuation of levator To improve quality control with the three-
muscles was noted in three continuous slices) dimensional transperineal ultrasonography, we ran-
(Fig. 1B). If diagnosis of levator avulsion was question- domly selected 15 women from 192 participants of the
able, we used the levatorurethra gap to confirm the Mothers Outcomes After Delivery study who deliv-
presence of avulsion. The levatorurethra gap is ered exclusively by cesarean without prior labor.
the distance between the center of the urethra and These women served as negative control participants
the medial aspect of the levator muscle insertion on in the ultrasound protocol because they were not
the inferior pubic ramus, as shown in Figure 2A. This expected to have any levator trauma. Additionally,
gap increases with detachment of the levator muscle their inclusion blinded the investigators performing
from pelvic side walls,12 as shown in Figure 2B. A and interpreting the ultrasound volumes to womens
levatorurethra gap of 25 mm or more at the plane obstetric history.
of minimal hiatal dimension and in the two slices The primary analysis was a comparison of levator
cephalad to this plane on either side of the body has ani muscle avulsion between women with forceps-
been shown to have a sensitivity of 63% and a speci- assisted delivery and women with vacuum-assisted
ficity of 94% for diagnosis of levator avulsion in Cau- delivery. Sample size was calculated for this aim. Prior
casian women.12 Measurement of the levatorurethra publications suggest that incident levator ani muscle
gap is reproducible and correlates with levator injury occurs in 5065% of women after forceps-
symphysis gap, a measure of levator ani muscle assisted vaginal delivery.10 The incidence of levator
avulsions on magnetic resonance imaging.13 injury after a vacuum delivery is not as well estab-
Additional outcomes of interest included the lished but we anticipated that 1020% of women with
anteroposterior diameter of the hiatus, area of the a history of vacuum delivery would have a levator
hiatus, and change in hiatal area from rest to pelvic injury.9,10 For our power calculations, we assumed
floor muscle contraction and from rest to Valsalva. a type I error probability of .05. We also anticipated
Anteroposterior hiatal diameter was measured as the that participation would be similar in the two groups,
shortest distance from the posteroinferior margin of and, therefore, the ratio of forceps to vacuum partic-
the symphysis pubis to the rectal sling in the mid- ipants would be 7:5. Based on these assumptions, we
sagittal plane at rest, Valsalva, and pelvic floor calculated a sample size of 96 (56 women in the for-
muscle contraction.14 We measured hiatal area at ceps delivery group and 40 women in the vacuum
the plane of minimal hiatal dimension on rest, Val- delivery group) for the purpose of having 80% power
salva, and pelvic floor muscle contraction volumes. to reject the null hypothesis that there is no difference

Fig. 1. A. Ultrasound image (axial


plane) of a normal levator ani mus-
cle. B. Ultrasound image (axial
plane) of a right-sided levator ani
muscle avulsion. *A right-sided
levator ani muscle avulsion.
Memon. Levator Injury After Operative
Vaginal Birth. Obstet Gynecol 2015.

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and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Fig. 2. A. Ultrasound image (axial
plane) showing a normal levator
urethra gap of less than 25 mm
bilaterally. B. Ultrasound image
(axial plane) showing right-sided
levator avulsion with a right levator
urethra gap of greater than 25 mm
(white arrow).
Memon. Levator Injury After Operative
Vaginal Birth. Obstet Gynecol 2015.

in the prevalence of levator ani muscle avulsion inju- of forceps delivery were slightly older at their index
ries between the two groups. We evaluated differences delivery as compared with women with a history of
between the two delivery groups in secondary out- vacuum delivery, although this difference was not sta-
comes of hiatal dimensions as well as demographic tistically significant. Both delivery groups had a similar
and obstetric characteristics using Wilcoxon rank- time interval from index delivery to the ultrasound
sum test for continuous variables and Fisher exact test study (median interval 10.3 compared with 9.8 years,
for categorical variables. Pelvic floor disorder out- P5.73). Three participants experienced two operative
comes were also compared between the two delivery vaginal deliveries.
groups using x2 conditional exact test. A P value In terms of the obstetric characteristics, the
threshold of .05 was used for inference testing. All majority of women in both groups were multiparous.
analysis was performed using SAS 9.3. More women in the forceps delivery group had
a history of a prolonged second stage of labor
RESULTS compared with women in the vacuum delivery group,
We identified a subset of 127 women from the but this difference was not statistically significant.
participants of Mothers Outcomes After Delivery There was no significant difference in the rates of
study who had history of either forceps or vacuum- episiotomy between the two groups. Most episioto-
assisted vaginal delivery but not both types of mies performed at the time of operative delivery
operative vaginal deliveries. Five of these women (36/48) were midline with no difference in episiotomy
were excluded because the history of operative type between groups (P5.29). The only statistically
vaginal delivery was reported by the participant but significant difference between the two vaginal delivery
could not be verified from the medical records. Two groups was in history of anal sphincter laceration,
additional women were excluded because they were which was more common among women in the
pregnant at the time of ultrasound study. A total of forceps-assisted delivery group compared with
120 women met our eligibility criteria and were women in the vacuum delivery group (53% compared
offered participation. Among these eligible partici- with 18%, P5.006).
pants, a total of 75 women agreed to participate and Substantial differences were observed in the
underwent three-dimensional transperineal ultrasono- proportion of women with levator trauma in the
grams. Two of these 75 participants were excluded forceps compared with vacuum groups. We identi-
from the final analysis as a result of missing or fied levator avulsions among 22 of 45 women (49%)
uninterpretable volumes. Thus, 73 women were who had undergone forceps delivery compared with
included in the final analysis. This included 45 women 5 of 28 who had undergone vacuum delivery (18%;
with a forceps delivery history and 28 women with P5.012). Thus, the prevalence ratio was 2.74 (95%
a vacuum delivery history. There were no differences confidence interval [CI] 1.176.40) and the odds
in the demographic characteristics or obstetric factors ratio was 4.40 (95% CI 1.4213.62). Among the 10
of women who were included in the final analysis unlabored cesarean delivery women serving as neg-
(n573) and those who were not included (n547), as ative control participants, nine had interpretable
shown in Appendix 1. Among 15 randomly selected ultrasound volumes, of which none were found to
women in the unlabored cesarean delivery group, 10 have levator injury.
women agreed to participate. Women in the forceps group also had wider hiatal
Women in the forceps and vacuum delivery areas and larger anteroposterior hiatal diameters at
groups were comparable in most demographic fac- rest, squeeze, and Valsalva (Table 2). These women
tors, as summarized in Table 1. Women with a history also had a larger change in the hiatal area from rest to

VOL. 125, NO. 5, MAY 2015 Memon et al Levator Injury After Operative Vaginal Birth 1083

Copyright by The American College of Obstetricians


and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Table 1. Demographic and Obstetric Characteristics of 73 Participants by Delivery Group

Characteristic Forceps (n545) Vacuum (n528) P*

Current parity
1 14 (31) 6 (20) .53
2 21 (47) 13 (46)
3 or more 10 (22) 9 (30)
BMI (kg/m2) at ultrasonography 24 (22, 25) 24 (21, 26) .69
African American race 2 (4) 3 (11) .37
Age at first delivery (y) 33 (30, 35) 31 (28, 33) .091
Age at index delivery (y) 34 (31, 36) 32 (29, 34) .12
Age at ultrasonography (y) 43 (40, 46) 42 (39, 45) .28
Years from index operative delivery to ultrasonography 10.3 (8.5, 11.7) 9.8 (7.3, 12.4) .73
Heaviest vaginal birth weight (g) 3,510 (3,210, 3,810) 3,510 (3,215, 3,850) .97
Birth weight at index operative vaginal birth (g) 3,400 (3,125, 3,745) 3,405 (3,070, 3,510) .33
Any vaginal birth with 2nd stage longer than 120 min 23 (51) 9 (32) .15
2nd stage longer than 120 min at index operative vaginal birth 21 (47) 8 (29) .15
At least 1 episiotomy 31 (69) 23 (82) .28
Episiotomy at index operative vaginal birth 28 (67) 20 (71) .79
Type of episiotomy at index operative vaginal birth .29
Midline 18/28 (64) 18/20 (90)
Mediolateral 6/28 (21) 1/20 (5)
At least 1 perineal laceration 22 (49) 15 (54) .81
Perineal laceration at index operative delivery 15 (35) 8 (29) .61
At least 1 anal sphincter laceration 24 (53) 5 (18) .006
Anal sphincter laceration at index operative vaginal birth 24 (53) 5 (18) .002
BMI, body mass index.
Data are frequency (%) or median (interquartile range) unless otherwise specified.
* Based on Fisher exact tests for categorical variables and Wilcoxon rank-sum tests for continuous variables.

Missing data: maternal age at index operative delivery, n53; episiotomy at index operative delivery, n53; perineal laceration at index
operative delivery, n52; anal sphincter laceration at index operative delivery, n54.

For these variables, maternal self-report was substituted if obstetric record data were missing.

Valsalva, indicating greater ballooning of the hiatus Table 3 summarizes the prevalence of pelvic floor
with Valsalva after a forceps delivery. Additionally, disorders between women with levator ani muscle
we observed less change in hiatal area from rest to avulsion injury and those without levator ani after
squeeze among women with a history of forceps deliv- adjusting for the type of operative vaginal delivery.
ery, indicating less closure of the levator hiatus with As shown in Table 3, irrespective of the delivery
voluntary levator contraction. group, women with levator ani muscle avulsion inju-
Although the prevalence of anal sphincter lacer- ries tended to have a higher prevalence of pelvic floor
ation (53%) and the levator ani muscle avulsion (49%) disorders (especially stress incontinence and prolapse)
was similar among women in the forceps delivery compared with women without levator ani muscle
group, these were not the same women. Only 11 of 24 avulsion injuries. However, the only statistically sig-
(46%) women in the forceps group with a history of nificant difference found was for prolapse symptoms,
anal sphincter laceration had evidence of levator which were significantly more common among
avulsion. In comparison, among 21 women in the women with levator avulsion (P5.036).
forceps group with no history of anal sphincter
laceration, 11 (52%) had levator avulsion. We did DISCUSSION
not find a statistically significant association between We observed a significant difference in the prevalence
anal sphincter laceration and levator ani muscle of levator avulsion between the forceps and vacuum
avulsion (Fisher exact test, P5.77). In addition, on delivery groups 10 years after operative vaginal birth.
multivariate analysis, the association between levator Other investigators have reported similar findings
ani muscle avulsion and forceps delivery did not among women evaluated in the first year after
change after adjusting for history of anal sphincter delivery. Kearney et al10 reported levator muscle
laceration. Of note, our analysis was not adequately injury in 6 of 18 women 912 months after forceps
powered to study the association between levator birth compared with 2 of 12 after vacuum birth. Sim-
avulsion and anal sphincter laceration. ilarly, levator avulsions were more common at 4

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Table 2. Secondary Outcome Measures by avulsions resolve over time.17,18 Our study provides
Delivery Group for 73 Women evidence for a persistent effect of forceps delivery on
levator ani muscles.
Forceps Vacuum We also identified differences in levator function
Characteristic (n545) (n528) P*
between the groups. Women in the forceps group had
Hiatal area (cm2) a wider levator hiatus, a smaller decrease in hiatal area
Rest 17 (14, 19) 15 (13, 17) .059 with pelvic floor contraction, and greater widening of
Pelvic floor muscle 15 (12, 17) 11 (10, 14) .004 the hiatus area with Valsalva. These findings suggest
contraction
a decreased ability to close the hiatus during a levator
Valsalva 22 (18, 30) 17 (14, 24) .019
Change in area from contraction and an inability of the avulsed levator
rest (cm2) muscle to maintain hiatal dimensions with increased
Pelvic floor muscle 22 (23, 0) 23 (23, 21) .054 abdominal pressure.
contraction We found that women with levator ani muscle
Valsalva 7 (2, 10) 4 (1, 6) .072
avulsion were significantly more likely to report
Anteroposterior hiatal
diameter (cm) prolapse symptoms, independent of delivery type.
Rest 6 (5, 6) 5 (5, 5) .024 Other pelvic floor conditions were marginally more
Pelvic floor muscle 5 (4, 6) 4 (4, 5) ,.001 common among women with levator ani avulsion,
contraction but differences were not statistically significant. Our
Valsalva 6 (6, 7) 5 (5, 6) .004
findings raise the question of whether levator injury
Data are median (interquartile range) unless otherwise specified. could explain the known association between for-
* Derived from Wilcoxon rank sum test.
ceps and pelvic floor disorders.24 However, this
study was not adequately powered to test this
months postpartum among Australian women who hypothesis. Our results argue in favor of a study
had forceps delivery compared with women who with a sufficient sample size to simultaneously
had vacuum delivery (7/20 compared with 3/34, investigate the effect of operative delivery and leva-
P5.017).9 Finally, 8 weeks after delivery, levator avul- tor avulsion on the development of pelvic floor
sions were significantly more common among Chi- disorders.
nese women delivered by forceps (16/48) compared There are several strengths of this study. The
with vacuum (10/14).8 Our study not only supports investigators were blinded to patients obstetric expo-
the findings of these studies, but it also provides evi- sures. We used well-defined and validated techniques
dence for a persistent effect of forceps delivery for assessment of levator avulsion. Another strength is
a decade after the operative vaginal birth. Although that only those participants whose operative vaginal
the natural history of levator avulsion after childbirth delivery was confirmed from medical records were
is not well known, it has been suggested that some included in the study.

Table 3. Frequency of Pelvic Floor Disorders by Delivery Group and Levator Ani Muscle Avulsion Among
73 Participants

Forceps (n545) Vacuum (n528)


Avulsion Present Avulsion Absent Avulsion Present Avulsion Absent
Pelvic Floor Disorders* (n522) (n523) (n55) (n523) P

Stress urinary incontinence 9 (41) 6 (26) 1 (20) 2 (9) .25


Overactive bladder 4 (18) 2 (9) 1 (20) 4 (17) .48
Anal incontinence 5 (23) 6 (26) 1 (20) 5 (22) .99
Pelvic organ prolapse 4 (18) 1 (4) 2 (40) 1 (4) .036
symptoms
Pelvic organ prolapse on 13 (59) 9 (39) 2 (40) 7 (30) .20
examination
Data are n (%) unless otherwise specified.
* Outcomes describe the event in question ever occurring across all visits of the longitudinal study before and including the visit at which
the ultrasonogram was performed.

Based on x2 conditional exact test evaluating differences between women with and without avulsion. Derived from multivariate logistic
model adjusting for operative delivery type.

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Although there was no difference between the 3. Friedman S, Blomquist JL, Nugent JM, McDermott KC,
Muoz A, Handa VL. Pelvic muscle strength after childbirth.
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evidence that vacuum may be a safer alternative to levator hiatus. Ultrasound Obstet Gynecol 2008;31:67680.
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1086 Memon et al Levator Injury After Operative Vaginal Birth OBSTETRICS & GYNECOLOGY

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and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Appendix 1: Demographic and Obstetric Characteristics of 120 Eligible Participants by Inclusion Status

Included in Final Analysis Not Included in Final Analysis


Characteristic (n573) (n547) P*

Current parity .71


1 20 (27) 14 (30)
2 34 (47) 24 (51)
3 or more 19 (26) 9 (19)
African American race 5 (7) 5 (11) .51
Age at first delivery (y) 32 (29, 35) 33 (29, 37) .39
Age at index delivery (y) 33 (30, 36) 34 (30, 36) .43
Heaviest vaginal birth weight (g) 3,510 (3,210, 3,820) 3,450 (3,290, 3,800) .63
Birth weight at index operative vaginal birth (g) 3,400 (3,125, 3,645) 3,300 (3,090, 3,705) .61
Any vaginal birth with 2nd stage longer than 120 min 32 (44) 27 (57) .19
2nd stage longer than 120 min at index operative 29 (40) 25 (53) .19
vaginal birth
At least 1 episiotomy 55 (75) 35 (74) .99
Episiotomy at index operative vaginal birth 48 (69) 33 (72) .84
Type of episiotomy at index operative vaginal birth .31
Midline 36 (75) 20 (61)
Mediolateral 7 (15) 6 (18)
At least 1 perineal laceration 37 (51) 25 (53) .85
Perineal laceration at index operative delivery 23 (32) 13 (28) .68
At least 1 anal sphincter laceration 29 (40) 21 (45) .70
Anal sphincter laceration at index operative vaginal 29 (42) 21 (51) .43
birth
Data are frequency (%) or median (interquartile range) unless otherwise specified.
* Based on Fisher exact tests for categorical variables and Wilcoxon rank-sum tests for continuous variables.

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