activation is associated with a longer active second stage of labor in nulliparous women undergoing induction of labor Rasha Kamel MD PhD 1 Elisa Montaguti ID: 934116
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Slide1
Levator ani muscle co-activation is associated with a longer active second stage of labor in nulliparous women undergoing induction of labor
Rasha Kamel, MD, PhD,1 Elisa Montaguti, MD2, Kypros H. Nicolaides, MD 3 Mahmoud Soliman, MD, PhD,1 Maria Gaia Dodaro, MD2, Sherif Negm, MD, PhD,1 Gianluigi Pilu, MD, PhD2, Mohamed Momtaz, MD, PhD,1 Aly Youssef From the Departments of Obstetrics and Gynecology, Kasr Al-Ainy University Hospital, Cairo University, Egypt1, Sant’Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy2, and Harris Birthright Research Center for Fetal Medicine, King’s College, London, UK 3
Graphic art by Alessandro
Meggio- 3DShift srl (3d.ameggio@gmail.com)
Slide2BackgroundValsalva maneuver, whereby the mother is asked to take a deep breath, hold the breath and push downward when uterine contraction starts, is normally accompanied by relaxation of the levator ani muscle, which stretches around the
presenting partIn some women the maneuver is accompanied by levator ani muscle contraction, which is referred to as co-activation
Slide3BackgroundBy transperineal ultrasound, levator ani muscle co-activation is diagnosed when the anteroposterior diameter of the levator hiatus under Valsalva maneuver is less than that in the resting state
Slide4Proper relaxation of the levator ani muscle at Valsalva
The anteroposterior diameter of the levator hiatus INCREASES under Valsalva
Slide5Levator ani muscle co-activation
The anteroposterior diameter of the levator hiatus DECREASES under Valsalva
Slide6Material and methods
The study was conducted in two tertiary level university hospitals (Bologna University Hospital and Cairo University Hospital).We recruited a series of nulliparous women with singleton pregnancies undergoing induction of labor at termWe performed transperineal ultrasound to all women prior to induction of labor, measuring the anteroposterior diameter of the levator hiatus at rest and under maximum Valsalva
Slide7Results
Overall, 138 women were included in the analysisDelivery was spontaneous vaginal in 92 (66.7%), by vacuum in 6 (4.4%) and Cesarean in 40 (28.9%) women.There were no significant differences between women who underwent spontaneous vaginal delivery in comparison with the Cesarean delivery group as regards the anteroposterior diameter of the levator hiatus at rest and at maximum Valsalva, nor in the prevalence of levator ani muscle co-activation.
Slide8ResultsVariableCo-activation(n=25)No co-activation
(n=113)P value*Gestational age at induction (weeks)39.0±1.539.2±1.50.521Maternal age (years)30.0±7.027.2±6.4
0.055
Body mass index (kg/m2)29.9±6.5
29.7±5.1
0.903
Epidural analgesia
8 (32.0)
21 (18.6)
0.174
Induction to delivery interval (min)
1368±456
1540±764
0.280
Duration of second stage (min)**
101±59
71±76
0.067
Duration of active second stage (min)**
60±56
28±16
<0.001
Women with levator ani muscle co-activation had a longer active second stage of labor in comparison with women with no
co-activation
Slide9Results
At Cox regression analysis, adjusted for potential significant confounders (maternal age and epidural analgesia), levator ani muscle co-activation was the only significant and independent predictor of the duration of the active second stage (hazard ratio 2.085, 95% confidence interval 1.158 – 3.752; P=0.014)
Slide10ConclusionsLevator ani co-activation is associated with a longer active second stage of labor.Further studies are needed to assess the benefit of specific corrective measures in the subgroup of women with co-activation.