The impact of variations in obstetric practice on maternal birth trauma.

INTRODUCTION AND HYPOTHESIS: Forceps delivery and length of second stage are risk factors of maternal birth trauma, i.e., levator ani muscle (LAM) avulsion and anal sphincter trauma. The cesarean section (CS) rate has recently become the key performance indicator because of its increase worldwide. Attempts to reduce CS rates seem to have led to an increase in forceps deliveries and longer second stages. This study aimed to determine the association between variations in obstetric practice (between hospitals) and maternal birth trauma. METHODS: This was a retrospective ancillary analysis involving 660 nulliparous women carrying an uncomplicated singleton term pregnancy in a prospective perinatal intervention trial at two Australian tertiary obstetric units. They had been seen antenatally and at 3-6 months postpartum for a standardized clinical assessment between 2007 and 2014. Primary outcome measures were sonographically diagnosed LAM and external anal sphincter (EAS) trauma. RESULTS: The incidence of LAM avulsion (11.5% vs. 21.3%, P = 0.01) and composite trauma, i.e., LAM avulsion ± EAS injury (29.2% vs. 39.7%, P = 0.03) were higher in one of the two hospitals, where the forceps delivery rate was also higher (10.9% vs. 2.6%, P < 0.001). BMI (OR 0.9, P = 0.02), length of second stage (OR 1.01, P = 0.02) and forceps delivery (OR 5.24, P < 0.001) were significant predictors of the difference in LAM avulsion incidence between the hospitals. Maternal age (OR 1.06, P < 0.04) and forceps delivery (OR 8.66, P < 0.001) were significant predictors for composite trauma. CONCLUSIONS: A higher incidence of LAM avulsion and composite trauma in one of the two hospitals was largely explained by a higher forceps delivery rate.

Normal Values of Anal Sphincter Biometry by 4-Dimensional Translabial Ultrasound: A Retrospective Study of Pregnant Women in Their Third Trimester.

OBJECTIVES: Exoanal 4-dimensional translabial ultrasound (TLUS) is increasingly used to image the anal sphincter. The aim of this study was to define the limits of normality for assessment of external and internal anal sphincters with TLUS. METHODS: This study was a retrospective analysis using data sets of nulliparous women seen antenatally. All women had a 4-dimensional TLUS examination at a mean gestational age ± SD of 36 ± 0.7 (range, 32.9-37.3) weeks. Anal sphincter biometry, including external anal sphincter (EAS) length and thickness, EAS proximal rotational asymmetry, and internal anal sphincter thickness, was assessed blinded against other data. RESULTS: A test-retest series showed good repeatability (intraclass correlation coefficients, 0.619-0.849) of all parameters. The mean age of the women (n = 111) was 30.9 (range, 18.8-40.5) years. None reported anal incontinence. On tomographic imaging, none showed anal sphincter defects. The mean EAS length was 17.5 (range, 8.4-34.8) mm, being shorter dorsally at 16.4 (range, 7.0-32.7) mm versus 18.7 (range, 7.5-36.9) mm ventrally (P < .001). The ventral EAS reached farther cranially by 0.8 ± 2.5 (range, -4.8-5.1) mm on average. The mean EAS thickness was 3.4 (range, 2.0-5.8) mm, being thicker dorsally than ventrally (P < .001). CONCLUSIONS: Anal sphincter biometry can be assessed with good repeatability by TLUS. The EAS seems longer ventrally. Asymmetry of the EAS could result in a false-positive diagnosis of defects in women in whom the ventral EAS terminates more caudally than its dorsal aspect, which seems uncommon. Hence, the likelihood of a false-positive diagnosis of substantial defects of the EAS using the published method seems low.

Does Patient Posture Affect the Ultrasound Evaluation of Pelvic Organ Prolapse?

OBJECTIVES: Translabial ultrasound (US) imaging is an emerging method for the evaluation of pelvic organ prolapse (POP). Normative data to date are limited to imaging in the supine position. The purpose of this study was to evaluate the effect of posture changes on US pelvic organ mobility. METHODS: This work was a retrospective study of 175 women seen in a tertiary urogynecologic center for symptoms of lower urinary tract and pelvic floor dysfunction. All underwent a standardized interview, POP quantification prolapse assessment, and 4-dimensional translabial US examination in supine and standing positions. Offline measurement of organ descent on the Valsalva maneuver was undertaken at a later date and was blinded against all other data. RESULTS: The mean age was 58 (SD, 13.5; range, 17 to 89) years, with a mean body mass index of 29 (SD, 6.1; range, 18 to 53) kg/m2 . In total, 58.9% (n = 103) presented with symptoms of prolapse. Clinically, 82.8% (n = 145) had substantial prolapse on the POP quantification assessment. On imaging, bladder, uterine, and rectal ampulla positions were significantly lower, and the hiatal area on the Valsalva maneuver was larger in the standing position (P < .03). On receiver operating characteristic statistics assessing correlations between POP symptoms and US pelvic organ descent, the area under the curve was higher in the standing position, but the difference was not statistically significant. CONCLUSIONS: Measurements of organ descent and hiatal dimensions are generally higher in the standing position. However, they are not reflected in a stronger association between symptoms and organ descent. Hence, imaging in the standing position can be limited to those patients in whom a false-negative assessment result is suspected.

Atraumatic normal vaginal delivery: how many women get what they want?

BACKGROUND: Trauma to the perineum, levator ani complex, and anal sphincter is common during vaginal childbirth, but often clinically underdiagnosed, and many women are unaware of the potential for long-term damage. OBJECTIVE: In this study we use transperineal ultrasound to identify how many women will achieve a normal vaginal delivery without substantial damage to the levator ani or anal sphincter muscles, and to create a model to predict patient characteristics associated with successful atraumatic normal vaginal delivery. STUDY DESIGN: This is a retrospective, secondary analysis of data sets gathered in the context of an interventional perinatal imaging study. A total of 660 primiparas, carrying an uncomplicated singleton pregnancy, underwent an antepartum and postpartum interview, vaginal exam (Pelvic Organ Prolapse Quantification), and 4-dimensional translabial ultrasound. Ultrasound data were analyzed for levator trauma and/or overdistention and residual sphincter defects. Postprocessing analysis of ultrasound volumes was performed blinded against clinical data and analyzed against obstetric data retrieved from the local maternity database. Levator avulsion was diagnosed if the muscle insertion at the inferior pubic ramus at the plane of minimal hiatal dimensions and within 5 mm above this plane on tomographic ultrasound imaging was abnormal, ie the muscle was disconnected from the inferior pubic ramus. Hiatal overdistensibility (microtrauma) was diagnosed if there was a peripartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2. A sphincter defect was diagnosed if a gap of >30 degrees was seen in ≥4 of 6 tomographic ultrasound imaging slices bracketing the external anal sphincter. Two models were tested: a first model that defines severe pelvic floor trauma as either obstetric anal sphincter injury or levator avulsion, and a second, more conservative model, that also included microtrauma. RESULTS: A total of 504/660 women (76%) returned for postpartum follow-up as described previously. In all, 21 patients were excluded due to inadequate data or intercurrent pregnancy, leaving 483 women for analysis. Model 1 defined nontraumatic vaginal delivery as excluding operative delivery, obstetric anal sphincter injuries, and sonographic evidence of levator avulsion or residual sphincter defect. Model 2 also excluded microtrauma. Of 483 women, 112 (23%) had a cesarean delivery, 103 (21%) had an operative vaginal delivery, and 17 (4%) had a third-/fourth-degree tear, leaving 251 women who could be said to have had a normal vaginal delivery. On ultrasound, in model 1, 27 women (6%) had an avulsion and 31 (6%) had a residual defect, leaving 193/483 (40%) who met the criteria for atraumatic normal vaginal delivery. In model 2, an additional 33 women (7%) had microtrauma, leaving only 160/483 (33%) women who met the criteria for atraumatic normal vaginal delivery. On multivariate analysis, younger age and earlier gestation at time of delivery remained highly significant as predictors of atraumatic normal vaginal delivery in both models, with increased hiatal area on Valsalva also significant in model 2 (all P ≤ .035). CONCLUSION: The prevalence of significant pelvic floor trauma after vaginal child birth is much higher than generally assumed. Rates of obstetric anal sphincter injury are often underestimated and levator avulsion is not included as a consequence of vaginal birth in most obstetric text books. In this study less than half (33-40%) of primiparous women achieved an atraumatic normal vaginal delivery.

It is the first birth that does the damage: a cross-sectional study 20 years after delivery.

INTRODUCTION AND HYPOTHESIS: Levator ani muscle (LAM) and anal sphincter tears are common after vaginal birth and are associated with female pelvic organ prolapse and anal incontinence. The impact of subsequent births on LAM and external anal sphincter (EAS) integrity is less well defined. The objective of this study was to determine the prevalence of LAM and EAS trauma in primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally to assess if there were differences between the two groups. The null hypothesis was: there is no significant difference in the prevalence of LAM and EAS trauma between the two groups. METHODS: This was a cross-sectional study involving 195 women, participants of the Dunedin arm of the ProLong study (PROlapse and incontinence LONG-term research study) seen 20 years after their index birth. Assessment included a standardized questionnaire, ICS POP-Q and 4D translabial ultrasound. Post-imaging analysis of LAM and EAS integrity was undertaken blinded against other data. Statistical analysis was performed using Fisher's exact test and results were expressed as odds ratios (OR). RESULTS: LAM avulsion and EAS defects were diagnosed in 31 (16%) and 24 (12.4%) women respectively. No significant difference in the prevalence of levator avulsion and EAS defects between primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally (OR 1.9, 95% CI 0.72-5.01, p = 0.26) and (OR 1.2, 95% CI 0.4-3.8, p = 0.76) respectively. CONCLUSIONS: Most LAM avulsions and EAS defects seem to be caused by the first vaginal birth. Subsequent vaginal deliveries after the first were unlikely to cause further LAM trauma.

Can pelvic floor trauma be predicted antenatally?

INTRODUCTION: Levator trauma is a risk factor for the development of pelvic organ prolapse. We aimed to identify antenatal predictors for significant damage to the levator ani muscle during a first vaginal delivery. MATERIAL AND METHODS: A retrospective observational study utilizing data from two studies with identical inclusion criteria and assessment protocols between 2005 and 2014. A total of 1148 primiparae with an uncomplicated singleton pregnancy were recruited and assessed with translabial ultrasound at 36 weeks antepartum and 871 (76%) returned for reassessment 3-6 months postpartum. The ultrasound data of vaginally parous women were analyzed for levator avulsion and microtrauma. The former was diagnosed if the muscle insertion at the inferior pubic ramus in the plane of minimal hiatal dimensions and within 5 mm above were abnormal on tomographic ultrasound imaging. Microtrauma was diagnosed in women with an intact levator and if there was a postpartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2 . RESULTS: The complete datasets of 844 women were analyzed. Among them, 609 delivered vaginally: by normal vaginal delivery in 452 (54%), a vacuum birth in 102 (12%) and a forceps delivery in 55 (6%). Levator avulsion was diagnosed in 98 and microtrauma in 97. On multivariate analysis, increasing maternal age, lower body mass index and lower bladder neck descent were associated with avulsion. Increased bladder neck descent and a family history of cesarean section (CS) were associcated with microtrauma. CONCLUSIONS: Maternal age, body mass index, bladder neck descent and family history of CS are antenatal predictors for levator trauma.

Intrapartum predictors of maternal levator ani injury.

INTRODUCTION: Damage to the pelvic floor during vaginal childbirth is common, and may take the form of levator avulsion or irreversible overdistension of the levator hiatus (microtrauma). Such trauma is a major risk factor for pelvic organ prolapse later in life. In this study we aimed to identify intrapartum risk factors for levator trauma. MATERIAL AND METHODS: This is a retrospective analysis of data obtained in two perinatal studies on primiparous women. Between 2005 and 2014, 1148 women carrying an uncomplicated singleton pregnancy in the late third trimester were seen for 4D pelvic floor ultrasound and an interview. They were invited for a repeat assessment at three months postpartum. RESULTS: Of 1148 women, 871 (76%) returned for assessment at a mean of five months postpartum. The datasets of 844 women were analyzed due to missing data or concurrent pregnancy in 27. In all, 452 (54%) had a normal vaginal delivery, 102 (12%) a vacuum, 55 (6%) a forceps, and 235 (28%) a cesarean section. On multivariate analysis forceps, length of second stage and obstetric anal sphincter tears were significantly associated with levator avulsion. There were no significant predictors identified for irreversible overdistension. CONCLUSIONS: The use of forceps, a prolonged second stage, and obstetric anal sphincter tears were associated with levator avulsion. There were no associated intrapartum predictors for hiatal overdistension.

The association between maternal age at first delivery and risk of obstetric trauma.

BACKGROUND: There are a number of poor birth outcomes with advancing maternal age. Although there is some evidence of a higher risk of trauma to obstetric anal sphincter and the levator ani muscle with advancing age, findings to date are inconclusive. OBJECTIVE: The aim of this study was to assess the risk of pelvic floor injury using translabial 3- and 4-dimensional ultrasound relative to advancing maternal age in primiparous women after a singleton vaginal delivery at term and to determine any association between maternal age and obstetric trauma, including obstetric anal sphincter injuries, levator avulsion, and irreversible overdistension of the levator hiatus. STUDY DESIGN: This is a subanalysis of a perinatal intervention trial conducted in a specialist urogynecology referral unit at 2 tertiary units. All primiparous women with singleton birth at term underwent 3- and 4-dimensional translabial pelvic floor ultrasound both ante- and postnatally for the assessment of the obstetric trauma including levator ani muscle avulsion, hiatal overdistension to 25 cm(2) or more, and obstetric anal sphincter injuries. A multivariate logistic regression analysis was performed to examine the association between maternal age and obstetric trauma diagnosed on 3- and 4-dimensional translabial ultrasound. Multiple confounders were included, and the most significant (forceps and vacuum delivery) were used for probability modeling. RESULTS: Of 660 women recruited for the original study, a total of 375 women who had a vaginal delivery with complete data sets were analyzed. A total of 174 women (46.4%) showed evidence of at least 1 form of major pelvic floor trauma. Advancing maternal age at first delivery carries with it a significant incremental risk of major pelvic floor trauma with an odds ratio of 1.064 for overall risk of injury for each increasing year of age past age 18 years (P = .003). The probability of any type of trauma appears to be substantially higher for forceps delivery. Vacuum delivery appears to increase the risk of obstetric anal sphincter injuries but not of levator avulsion. CONCLUSION: There is a significant association between the risk of major pelvic floor injury and increasing maternal age at first delivery.

The prevalence of abnormal posterior compartment anatomy and its association with obstructed defecation symptoms in urogynecological patients.

INTRODUCTION AND HYPOTHESIS: Symptoms of obstructive defecation (OD) are common in women. Transperineal ultrasound (TPUS) has been used for the evaluation of defecatory disorders. The aim of our study was to determine the overall prevalence of anatomical abnormalities of the posterior compartment and their correlations with OD in women seen in a tertiary urogynecology clinic. METHODS: This is a retrospective study on 750 women seen at a tertiary urogynecological unit who had undergone a standardized interview, clinical examination, and 4D TPUS. Univariate and multivariate logistic regression analyses were undertaken to study the association between examination findings and symptoms of OD. This study was approved by the local human research ethics committee (Nepean Blue Mountains Local Health District Human Research Ethics Committee, IRB approval no. 13-16). RESULTS: The datasets of 719 women were analyzed. Mean age was 56.1 (18.4-87.6) years. Ninety-seven patients (13 %) reported fecal incontinence, 190 (26 %) constipation, and 461 (64 %) symptoms of OD. On examination, 405 women (56 %) were diagnosed with significant posterior compartment prolapse (POP-Q ≥ stage 2), which was associated with symptoms of OD (p < 0.0001). On ultrasound, 103 (14 %) patients had an enterocele, 382 (53 %) a true rectocele and 31 (4.3 %) had rectal intussusception. On multivariate analysis true rectocele (p = 0.003) and rectal intussusception (p = 0.004) remained significantly associated with symptoms of OD. CONCLUSION: Both symptoms of OD and anatomical abnormalities of the posterior compartment are highly prevalent in urogynecological patients. Ultrasound findings of a true rectocele and rectal intussusception are significantly associated with obstructed defecation.

Levator ani trauma and pelvic organ prolapse - a comparison of three translabial ultrasound scoring systems.

INTRODUCTION: The study aimed to analyze the relation between the degree of puborectalis muscle trauma and subjective symptoms and objective findings of pelvic organ prolapse (POP), comparing two continuous scoring systems with a discrete scoring system for translabial ultrasound imaging. MATERIAL AND METHODS: In this retrospective observational study the records of patients attending a tertiary urogynecological unit between January 2012 and December 2014 were analyzed. POP assessment included a standardized interview, clinical examination using Pelvic Organ Prolapse Quantification and four-dimensional translabial ultrasound. Puborectalis muscle trauma was assessed with tomographic ultrasound imaging using two continuous scoring systems and a previously established discrete system. Receiver operating characteristics and adjusted odds ratios were used for comparison of scoring systems in predicting symptoms and signs of POP. RESULTS: Of 1258 women analyzed, 52.6% complained of prolapse symptoms. On ultrasound imaging, 65.7% of women had sonographically significant POP. Complete avulsion was diagnosed in 25.3% of women, being unilateral in 13.9% and bilateral in 11.4%. A maximum score in the 6-point and the 12-point tomographic ultrasound imaging scale increased the odds for a diagnosis of any significant POP on ultrasound by 4.4 and 4.8 times, respectively, compared with 4.6 times for the discrete diagnosis of bilateral avulsion. For all avulsion scoring systems the relation was strongest for cystocele and uterine prolapse. CONCLUSIONS: A continuous avulsion scoring system based on tomographic findings does not provide superior performance for the prediction of subjective symptoms and objective findings of prolapse compared with a discrete diagnostic system of unilateral or bilateral avulsion.

Defect-specific rectocele repair: medium-term anatomical, functional and subjective outcomes.

BACKGROUND: Rectocele is a herniation of the anterior wall of the rectal ampulla through a defect in the rectovaginal septum causing protrusion of the posterior vaginal wall. Common symptoms include symptoms of prolapse and obstructed defecation. AIMS: To describe subjective, anatomical and functional results of defect-specific rectocele repair. MATERIALS AND METHODS: This is an internal audit of 137 women who underwent defect-specific rectocele repair. Pre- and post-operative assessment included a standardised interview, clinical examination and 3D/4D transperineal ultrasound. Outcome measures were symptoms of obstructed defecation, recurrent prolapse symptoms, clinical posterior compartment recurrence and rectocele recurrence on ultrasound. RESULTS: At a mean follow-up of 1.4 years, 117 (85%) of women considered themselves cured or improved. Thirty-four (25%) complained of recurrent prolapse symptoms and 47 (34%) symptoms of obstructed defecation, a significant reduction (P < 0.0001). Clinical recurrence (Bp ≥ -1) was seen in 19 women (14%) and recurrence on ultrasound in 27 (20%). The mean depth of recurrence was 16.6 mm (10.3-25.1). We tested multiple potential predictors of recurrence, including age, BMI, vaginal parity, previous hysterectomy and/or prolapse surgery, follow-up time, pre-operative clinical and ultrasound findings. Only hiatal area on Valsalva (OR 0.95 for sonographic recurrence, P = 0.01) and enterocele (for clinical and sonographic recurrence, OR 4.03, P = 0.01 and OR 2.72, P = 0.02, respectively) reached significance. CONCLUSION: Defect-specific rectocele repair is effective both in restitution of normal anatomy and in resolving prolapse and obstructed defecation symptoms at a mean follow-up of 1.4 years.

Negative urodynamic testing in women with stress incontinence.

INTRODUCTION: A minority of women with a subjective complaint of stress urinary incontinence will have negative urodynamic stress incontinence (USI) findings. AIM: To test clinical and ultrasound measures as predictors of an unexpected absence of USI. We hypothesised that unexpectedly negative USI would be more common in young women with good pelvic floor and urethral function. METHODS: A retrospective study analysing 398 data sets from women attending a urogynaecology clinic for evaluation of lower urinary tract and pelvic floor dysfunction. Clinical, urodynamic and translabial ultrasound data were tested as possible predictors of negative USI findings. RESULTS: Women with unexpectedly negative USI findings were younger, had less anterior compartment prolapse and had a higher maximum urethral pressure. Measures of pelvic floor muscle function were not predictive. CONCLUSIONS: Women with unexpectedly negative USI are younger and have better urethral function, but voluntary pelvic floor muscle function seems unrelated to this phenomenon.

Maternal COVID-19 vaccine acceptance among Malaysian pregnant women: A multicenter cross-sectional study.

Introduction: The coronavirus disease 2019 (COVID-19) caused a global pandemic that resulted in devastating health, economic and social disruption. Pregnant mothers are susceptible to COVID-19 complications due to physiological and immunity changes in pregnancy. We aimed to assess the maternal vaccine acceptance of the COVID-19 vaccine. Methods: A multi-center study across four teaching hospitals in the Klang Valley, Malaysia was conducted between September 2021 and May 2022. A survey was conducted using a self-administered electronic questionnaire. The survey instruments included; (1) maternal perception and attitude toward COVID-19 vaccination, (2) COVID-19 pregnancy-related anxiety, and 3) generalized anxiety disorder. Results: The response rate was 96.6%, with a final number for analysis of 1,272. The majority of our women were Malays (89.5%), with a mean age (standard deviation, SD) of 32.2 (4.6). The maternal vaccine acceptance in our study was 77.1%. Household income (p < 0.001), employment status (p = 0.011), and health sector worker (p = 0.001) were independent predictors of maternal willingness to be vaccinated. COVID-19 infection to self or among social contact and greater COVID-19 pregnancy-related anxiety were associated with increased odds of accepting the SARS-CoV-2 vaccine. Women who rely on the internet and social media as a source of vaccine information were more likely to be receptive to vaccination (adjusted odd ratio, AOR 1.63; 95% CI 1.14-2.33). Strong correlations were observed between maternal vaccine acceptance and the positive perception of (1) vaccine information (p < 0.001), (2) protective effects of vaccine (p < 0.001), and (3) getting vaccinated as a societal responsibility (p < 0.001). Discussion: The high maternal vaccine acceptance rate among urban pregnant women in Malaysia is most likely related to their high socio-economic status. Responsible use of the internet and social media, alongside appropriate counseling by health professionals, is essential in reducing vaccine hesitancy among pregnant women.

Effects of Eurycoma longifolia Jack standardised water extract (Physta) on well-being of perimenopausal and postmenopausal women: protocol for a randomised, double-blinded, placebo-controlled, parallel group study.

INTRODUCTION: Eurycoma longifolia Jack (EL), profoundly recognised as 'Tongkat Ali', is a medicinal herb originating from Southeast Asia. It is commonly used in traditional 'antiageing' treatments to address decreased energy, mood, libido and hormonal imbalances. While the benefits of EL have been extensively studied among the male population, less attention has been given to its effects on women. Menopause can impact the overall well-being of middle-aged women and incorporation of herbal supplements can aid them in managing the menopausal symptoms. METHODS AND ANALYSIS: This 12-week randomised double-blind, placebo-controlled, parallel-group study aims to evaluate the efficacy of the standardised water extract of EL known as Physta in increasing the quality of life of perimenopausal and postmenopausal women. The study involves 150 women aged 40-55 years who score more than 61 on the Menopause-Specific Quality of Life (MENQOL) assessment. These participants will be randomised into three groups, receiving Physta at either 50 mg or 100 mg or a placebo. The outcomes measures include mood state, quality of life, fatigue, sleep quality, sexual function and pain score assessed using Profile of Mood State, MENQOL, Chalder Fatigue Scale, Pittsburgh Sleep Quality Index, Female Sexual Function Index and the Brief Pain Inventory questionnaires, respectively. The secondary outcome of the study includes full blood analysis, urine analysis, female reproductive hormone profiling, inflammatory and oxidative stress biomarkers analysis. ETHICS AND DISSEMINATION: The research protocol of the study was reviewed and approved by the Research Ethics Committee of Universiti Kebangsaan Malaysia (UKM/PPI/111/8/JEP-2021-898). The findings will be disseminated to participants, healthcare professionals and researchers via conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER: ACTRN12622001341718.

Comparison of Pregnancy Outcome between 4 and 6 cm Cervical os Dilatation to Demarcate Active Phase of Labour: A Cross-Sectional Study.

This is a cross-sectional study comparing pregnancy outcomes between participants with 4 and 6 cm of cervical os dilatation at the diagnosis of the active phase of labour. It was conducted in a single tertiary centre involving low-risk singleton pregnancies at or beyond 37 weeks with spontaneous onset of labour. A total of 155 participants were recruited, 101 in group 1 (4 cm) and 54 in group 2 (6 cm). Both groups were similar in mean maternal age, mean gestational age at delivery, ethnicity, median haemoglobin level at delivery, body mass index, and parity. There were significantly more participants in group 1 who needed oxytocin augmentation (p < 0.001) for the longer mean duration (p = 0.015), use of analgesia (p < 0.001), and caesarean section rate (p = 0.002). None of the women had a postpartum haemorrhage or a third- or fourth-degree perineal tear, and none of the neonates required admission to the neonatal intensive care unit. There were significantly more nulliparas who had a caesarean section as compared to multiparas. A cervical os dilatation of 6 cm reduces the risk of caesarean section by 11% (95% CI, 0.01-0.9) and increases three times more the need for analgesia (AOR = 3.44, 95% CI, 1.2-9.4). In conclusion, the demarcation of the active phase of labour at a cervical os dilatation of 6 cm is feasible without an increase in maternal or neonatal complications.

Levator ani muscle avulsion: Digital palpation versus tomographic ultrasound imaging.

OBJECTIVE: To determine the diagnostic performance of digital palpation of levator ani muscle (LAM) avulsion compared with translabial tomographic ultrasound imaging (TUI). METHODS: A cross-sectional study, incorporating 195 women involved in a longitudinal cohort study. Palpation for levator integrity was performed, followed by a four-dimensional translabial ultrasound. LAM avulsion defects were diagnosed in the presence of puborectalis muscle detachment from its insertion. Post-processing analysis of ultrasound volumes for LAM integrity on TUI was performed blinded against palpation findings. Agreement between methods was assessed using Cohen's κ. RESULTS: In all, 388 paired assessments of LAM bilaterally, were available. Sixteen (8.2%) unilateral avulsion defects were detected on palpation. Sonographically, 31 (16%) were diagnosed with avulsions: 4.6% bilateral and 11.3% unilateral. An overall agreement of 91% was observed between digital palpation and TUI, yielding a Cohen's κ of 0.32 (95% confidence interval 0.15-0.48) demonstrating "fair agreement": and implying 25% sensitivity, 98% specificity, 63% positive predictive value, and 92% negative predictive value. Analysis of the first and last 20 palpations showed no change in performance during the 13-day study period. CONCLUSION: Assessment of LAM avulsion defects by digital palpation is feasible but may require substantial training. Confirmation by imaging is crucial, especially if the diagnosis of avulsion may influence clinical management.

Psychometric Evaluation of the Malay Version of the Childbirth Experience Questionnaire (CEQ-My).

Negative childbirth experience may cause adverse psychological effects in postpartum mothers. The Childbirth Experience Questionnaire (CEQ) is a multidimensional tool designed to assess women's perceptions of labour and birth. We aim to validate the Malay version of the CEQ (CEQ-My) and evaluate its psychometric properties. The previously published Malay-translated CEQ was reviewed by a panel of experts and underwent minor changes. The original visual analogue scoring (VAS) was changed to a numerical scale. The reliability and construct validity of CEQ-My was assessed using Cronbach's alpha and exploratory analysis, respectively. Known-groups validation was conducted using the Mann−Whitney U test, whilst the inter-item correlations between CEQ-My and its subdomains were evaluated through Spearman's correlation. The final analysis involved 246 women. The questionnaire was easy to understand and all women preferred numeric scoring to the VAS. Based on the principal component factor analysis, we deleted one item and rearranged the domain for four items. The twenty-one items CEQ-My demonstrated good reliability with Cronbach's alpha of 0.77. Women who had spontaneous vaginal delivery demonstrated significantly greater CEQ-My scores than those who underwent operative delivery (p = 0.002). The domain of professional support was positively correlated to that of own capacity and participation (p-value of < 0.001 and 0.002, respectively). The CEQ-My is a valid and reliable instrument to assess Malaysian women's childbirth experiences. The easy-to-use electronic version of CEQ-My will improve future research and ease data collection.

Does pregnancy affect pelvic floor functional anatomy? A retrospective study.

OBJECTIVE: Vaginal childbirth is an established main aetiological factor in the pathogenesis of female pelvic floor dysfunction. However, pregnancy itself is also likely to have an effect. This study investigated the effect of pregnancy on pelvic floor functional anatomy. STUDY DESIGN: This was a retrospective observational study involving vaginally nulliparous women who presented to a tertiary urogynaecology unit with symptoms and signs of pelvic floor dysfunction between 2006 and 2014. Nulliparous women were compared with those who delivered exclusively by Caesarean Section (CS). All had undergone a standardised clinical interview, ICS POP-Q assessment and 3D/4D translabial pelvic floor ultrasound. Main outcome measures included sonographically determined pelvic organ position and hiatal dimensions on Valsalva and pelvic floor muscle contraction (PFMC). RESULTS: Of 2930 women seen during the study period, 242 had never given birth vaginally. One hundred and twenty-nine (53 %) were nulliparous, and 113 (47 %) were delivered by CS only. The CS group demonstrated significantly higher pelvic organ mobility in the anterior compartment (all P < 0.05) and a larger hiatal area on Valsalva (P = 0.004). All sonographic measures of pelvic floor muscle function demonstrated greater tissue displacement on PFMC in the CS group (all P < 0.05). CONCLUSIONS: Compared to nulliparas, women who delivered exclusively by CS showed increased pelvic organ descent on Valsalva and tissue displacement on PFMC, implying increased tissue elasticity/ compliance or reduced stiffness, consistent with a small permanent hormonal and/or mechanical effect of pregnancy.

New Benefits of Hydroxychloroquine in Pregnant Women with Systemic Lupus Erythematosus: A Retrospective Study in a Tertiary Centre.

OBJECTIVE: To determine pregnancy outcomes in women with systemic lupus erythematosus (SLE) who were treated with hydroxychloroquine in a tertiary center. METHODS: A retrospective study involving pregnant women with SLE who had antenatal follow-up and delivery in between 1 January 2007 and 1 January 2017. All participants were retrospectively enrolled and categorized into two groups based on hydroxychloroquine treatment during pregnancy. RESULTS: There were 82 pregnancies included with 47 (57.3%) in the hydroxychloroquine group and 35 (42.7%) in the non-hydroxychloroquine group. Amongst hydroxychloroquine users, there were significantly more pregnancies with musculoskeletal involvement (p = 0.03), heavier mean neonatal birthweight (p = 0.02), and prolonged duration of pregnancy (p = 0.001). In non-hydroxychloroquine patients, there were significantly more recurrent miscarriages (p = 0.003), incidence of hypertension (p = 0.01) and gestational diabetes mellitus (p = 0.01) and concurrent medical illness (p = 0.005). Hydroxychloroquine use during pregnancy was protective against hypertension (p = 0.001), and the gestational age at delivery had significant effect on the neonatal birthweight (p = 0.001). However, duration of the disease had a significant negative effect on the neonatal birthweight (p = 0.016). CONCLUSION: Hydroxychloroquine enhanced better neonatal outcomes and reduced adverse pregnancy outcomes and antenatal complications such as hypertension and diabetes.