Post partum perineal dysfunctions: a prospectic analysis of risk factors

Background Many risk factors have been recognized to explain postpartum perineal dysfunctions such as multiparity, operative delivery, prolonged second stage of labor, epidural analgesia, perineal lacerations and fetal macrosomia. The perineal damage is correlated to pregnancy and vaginal delivery due to direct mechanic trauma on muscles the elevator ani and anal sphincter, neurologic damage of pelvic floor nerves and connective-fascial lesion of the urogenital hiatus. During pregnancy there is an excessive pressure on the anterior perineum due to the weight of the gravid uterus and the direct pressure on the urogenital hiatus. During vaginal birth, all the muscular and ligamentous structures of the pelvic floor are exposed to intense pressure and traction forces in lateral and longitudinal directions. During impingement of the presenting part, the bladder is compressed between pubic bones and the fetal head with a consequent trauma that is directly correlated with the length of the expulsion phase. Health workers must be able to recognize, prevent and treat perineal dysfunctions during and after pregnancy. The aim of our study was to evaluate different maternal, neonatal and delivery-associated risk factors and analyze the pelvic floor alterations in the puerperium compared with the perineal function before birth. Methods 106 primiparae women were enrolled, 4-5 months after delivery they underwent to an interview in order to evaluate urinary and anal incontinence, perineal pain, dyspareunia and a clinic examination of the functioning of the pelvic floor with pubococcygeus test (PC test). They also filled a questionnaire about the functioning of their pelvic floor during pregnancy. In order to obtain information about the risk factors there were considered: job, maternal age, gestational age, maternal weight before pregnancy, weight at term, maternal diseases, type of delivery (spontaneous, operative, caesarian section), episiotomy, grade of lacerations, Kristeller maneuver, type of induction (if any), length of labor, length of second stage of labor, head circumference, newborn’s weight, epidural analgesia. Results Vaginal birth correlate with lower scores at PC test, urinary incontinence that is also associated with maternal age and weight, dyspareunia and perineal pain, especially in women who had operative delivery, episiotomy and/or lacerations. Epidural analgesia seems to be protective for postpartum dyspareunia (31,8% vs 44,2%). A significant correlation has been demonstrated between newborn head circumference and weight and perineal dysfunction after delivery probably due to longer labor and increased stretching of pelvic tissues. Conclusions Our data are in line with literature and underline that urinary symptoms tends to ameliorate after delivery demonstrating that pregnancy itself is a risk factor. Moreover, we discovered that in women with perineal dysfunction in postpartum the symptoms were worse than during pregnancy. If pregnancy is a risk factor for perineal dysfunctions, delivery is a worsening factor for a pre-existing situation or the appearing of new symptoms