2. Vaginal CHILDBIRTH
PELVIC FLOOR INJURY

3. PFD
POP UI FI
Sexual Dysfunction

4. The pelvic floor is primarily made up of the levator ani and coccygeus muscles (ie, paired puborectalis, pubococcygeus, and iliococcygeus).
The urethral and anal sphincter muscles are also part of the pelvic floor.

5. The endopelvic connective tissues lie superior to the pelvic floor muscles and connect to the pelvic side walls and sacrum.
The perineal membrane (ie, bulbocavernosus, transverse perineal, and ischiocavernosus muscles) lies external and inferior to the pelvic floor.

6. The innervation
The pudendal nerve innervates the external anal and urethral sphincter,
Direct connection of S2, S3, and S4 nerve fibers (MUSCLES)

18. Fascial injury
paravaginal defects as separation of the endopelvic fascia from its lateral attachment to pelvic side wall .
Leading to Urethral Hypermobility ,SUI, Poor Anterior Vaginal Support.

21. Effect of pregnancy and childbirth:
compression, stretching, or tearing of nerve, muscle, and connective tissue ..

22. Neural injury During labor and vaginal delivery
stretching and compression of the pelvic floor and the associated nerves Leading to demyelination and subsequent denervation .

23. The resultant stress incontinence persists if the pudendal nerve is completely transected, but resolves after distension injury.

25. Injury to the levator ani and coccygeus muscles
Loss of levator function (eg, due to traumatic disruption, denervation, or atrophy) may lead to widening of the urogenital hiatus and result in pelvic organ descent.

26. Pelvic floor muscle strength is decreased after vaginal delivery compared with women who had only cesarean deliveries.

28. Impaired connective tissue remodeling
During pregnancy
Post Partum

29. PREVALENCE IN PAROUS WOMEN
PFDs increases with increasing parity
UI: nulli: one: : or more: 23.9%
POP: nulli:0.6 one : births: or more:3.8%

30. Age
a risk factor for PFDs
Post menopause

31. Impact of age UI :20-39: 6.9 60-69: 23.3 POP :20-39 :1.6% 60-69 :4.1
Among Premenopausal :Parous are more likely to report UI

32. ROLE OF OBSTETRIC FACTORS
Pregnancy Urinary incontinence: 7 to 60 percent
The prevalence and severity of incontinence increase during the course of pregnancy .
The highest incidence (2nd tm)
Highest cumulative prevalence (3rd tm)

33. The prognosis :favorable(70% new onset UI :Resolve spontaneously ).
In 12 months post partum :the prevalence drops to 12-23%)
Also among women with persistent incontinence ,severity declines in the 1st year …

34. Mode of delivery Vaginal >Cesarean
Operative vaginal, particularly forceps delivery,
increase the risk of developing pelvic organ prolapse;
there are few data regarding this mode of delivery and urinary incontinence.
also increases the risk of anal sphincter laceration, which increases the risk of fecal incontinence.

35. Episiotomy
Episiotomy rates have been declining, given good evidence that does not support routine use of episiotomy.

37. Angle of Episiotomy
And Its
IMPORTANCE

41. Perineal Care

43. 3rd -4th degree Laceration
Management
Post OP Care
Future Pregnancies

45. APPROACH TO OBSTETRIC MANAGEMENT
Prophylactic pelvic floor muscle exercises
Decrease shortterm risk of UI up to 3months postpartum.
Cesarean delivery????????????

46. Some studies have calculated :
that 7 to 12 women would have to deliver only by cesarean to prevent one woman from having a PFD later in life, assuming that the observed associations are causa

47. Other
Birth weight
Maternal BMI
Constipation

48. The authors found that the lateral birth position had
the highest rate of intact perineum (66.6 % intact, 28.3 % lacerations requiring
suture), whereas squatting was associated with the highest rate of lacerations
(41.9 % intact perineum, 53.2 % lacerations requiring suture).

50. Prolonged labor
Selective use of operative vaginal delivery
Selective use of episiotomy
obesity and smoking

51. Postpartum Screening Card
The “postpartum screening card” is intended to record the presence of pelvic dysfunctions after delivery. The card is composed of five sections:
urinary incontinence,
anal incontinence
pelvic organ prolapse
pain and dyspareunia
Pelvic floor muscle dysfunction.

53. We now have moderately robust
epidemiological data at 12 and 20 years after delivery and objective pathophysiological data (pudendal nerve trauma and
levator defects/avulsion).

54. propose a scoring system (UR-CHOICE) to predict the risk of future PFD based on several major risk factors..

55. UR-CHOICE U UI before pregnancy R Race/ethnicity
C Child bearing started at what age?
H Height (mother’s height)
O Overweight (weight of mother, BMI )
I Inheritance (family history)
C Children (number of children desired)
E Estimated fetal weight

56. For Scoring :
ProLong (PROlapse and incontinence LONG-term research) 12-year database involving just fewer than 4,000 women
SWEPOP (SWEdish Pregnancy, Obesity, and Pelvicfloor) 20-year database of slightly fewer than 5,000 women.

57. The number of children desired will not be included in the logistic regression modelling and final score but will be used in counselling women (particularly those with a high score) who are considering an elective Caesarean section.

58. Caesarean section need to be
balanced against the potential risks associated with repeat Caesarean sections, in particular, with complications of placent praevia and accreta.