Forceps delivery is associated with increased risk of pelvic organ prolapse and muscle trauma: a cross-sectional study 16-24 years after first delivery.
OBJECTIVE
To study possible associations between mode of delivery and pelvic organ prolapse (POP) and pelvic floor muscle trauma 16-24 years after first delivery and, in particular, to identify differences between forceps and vacuum delivery.


METHODS
This was a cross-sectional study including 608 women who delivered their first child in 1990-1997 and were examined with POP quantification (POP-Q) and pelvic floor ultrasound in 2013-2014. Outcome measures were POP ≥ Stage 2 or previous prolapse surgery, levator avulsion and levator hiatal area on Valsalva. Univariable and multivariable logistic regression analyses and ANCOVA were applied to identify outcome variables associated with mode of delivery.


RESULTS
Comparing forceps to vacuum delivery, the adjusted odds ratios (aOR) were 1.72 (95% CI, 1.06-2.79; P = 0.03) for POP ≥ Stage 2 or previous prolapse surgery and 4.16 (95% CI, 2.28-7.59; P < 0.01) for levator avulsion. Hiatal area on Valsalva was larger, with adjusted mean difference (aMD) of 4.75 cm(2) (95% CI, 2.46-7.03; P < 0.01). Comparing forceps with normal vaginal delivery, the adjusted odds ratio (aOR) was 1.74 (95% CI, 1.12-2.68; P = 0.01) for POP ≥ Stage 2 or surgery and 4.35 (95% CI, 2.56-7.40; P < 0.01) for levator avulsion; hiatal area on Valsalva was larger, with an aMD of 3.84 cm(2) (95% CI, 1.78-5.90; P < 0.01). Comparing Cesarean delivery with normal vaginal delivery, aOR was 0.06 (95% CI, 0.02-0.14; P < 0.01) for POP ≥ Stage 2 or surgery and crude OR was 0.00 (95% CI, 0.00-0.30; P < 0.01) for levator avulsion; hiatal area on Valsalva was smaller, with an aMD of -8.35 cm(2) (95% CI, -10.87 to -5.84; P < 0.01). No differences were found between vacuum and normal vaginal delivery.


CONCLUSIONS
We found that mode of delivery was associated with POP and pelvic floor muscle trauma in women from a general population, 16-24 years after their first delivery. Forceps was associated with significantly more POP, levator avulsion and larger hiatal areas than were vacuum and normal vaginal deliveries. There were no statistically significant differences between vacuum and normal vaginal deliveries. Cesarean delivery was associated with significantly less POP and pelvic floor muscle trauma than were normal or operative vaginal delivery.
Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway.|Department of Obstetrics and Gynecology, Trondheim University Hospital, Trondheim, Norway.
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Volløyhaug
Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway.|Clinical Service, Trondheim University Hospital, Trondheim, Norway.
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Mørkved
Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
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Salvesen
Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway.|National Center for Fetal Medicine, Trondheim University Hospital, Trondheim, Norway.
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Salvesen
D000328:Adult; D001004:Anus Diseases / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000209:etiology / Q000473:pathology; D002585:Cesarean Section / Q000009:adverse effects / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008875:Middle Aged; D009664:Norway / Q000453:epidemiology; D010146:Pain / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000209:etiology / Q000473:pathology; D010298:Parity; D059952:Pelvic Floor Disorders / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000209:etiology / Q000473:pathology; D056887:Pelvic Organ Prolapse / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000209:etiology; D011247:Pregnancy; D011788:Quality of Life; D013525:Surgical Instruments / Q000009:adverse effects / Q000706:statistics & numerical data*; D014463:Ultrasonography; D014620:Vacuum Extraction, Obstetrical / Q000009:adverse effects / Q000706:statistics & numerical data*
Cesarean delivery; forceps delivery; levator avulsion; normal vaginal delivery; pelvic floor muscle trauma; pelvic organ prolapse; vacuum delivery