Accepted Manuscript

The association between maternal age at first delivery and risk of obstetric trauma
Dr. Philip Rahmanou, MD, MRCOG, Dr. Jessica Caudwell-Hall, MD, Dr. Ixora
Kamisan Atan, MD, Prof. Hans P. Dietz, PhD
PII:

S0002-9378(16)30117-X

DOI:

10.1016/j.ajog.2016.04.032

Reference:

YMOB 11063

To appear in:

American Journal of Obstetrics and Gynecology

Received Date: 5 January 2016

Revised Date:

6 April 2016

Accepted Date: 19 April 2016

Please cite this article as: Rahmanou P, Caudwell-Hall J, Kamisan Atan I, Dietz HP, The association
between maternal age at first delivery and risk of obstetric trauma, American Journal of Obstetrics and
Gynecology (2016), doi: 10.1016/j.ajog.2016.04.032.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
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Authors:

Dr. Philip RAHMANOU1 MD, MRCOG

Dr. Jessica CAUDWELL-HALL MD
Dr. Ixora KAMISAN ATAN2 MD
Prof. Hans P. DIETZ PhD

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The association between maternal age at first

delivery and risk of obstetric trauma

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From: Department of Urogynecology, Sydney Medical School Nepean,

University of Sydney, Penrith, New South Wales, Australia

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Present address:
1. Department of Urogynecology, Gloucestershire Hospitals NHS Foundation
Trust, Gloucestershire, United Kingdom
2. Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
Disclosure of interest
HP Dietz had received unrestricted educational grants from GE Medical.
other authors have no conflict of interest to declare.

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Funding
None received

All

Clinical Trial
Australian
New
Zealand
Clinical
Trial
Registry
(ANZCTR
ACTRN12609000592246). www.anzctr.org.au/BasicSearch.aspx

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Paper presented
Annual Meeting of the International Continence Society (ICS), Rio de Janeiro, Brazil
October 2014

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Correspondence to:
Dr. Philip Rahmanou
Gloucestershire Hospitals NHS Foundation Trust
Department of Urogynecology, Womens Centre, Gloucester Royal Hospital
Great Western Road, Gloucester, UK, GL1 3NN
Work Tel: +44 300 422 2337
Fax: +44 300 422 5595
Cellphone: +44 7990571628
Email: Philip.Rahmanou@glos.nhs.uk
Word Count
Abstract: 330

Main article: 2301

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Condensation of paper (25 words)
With advancing maternal age at first vaginal delivery there is significant

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incremental risk of major obstetric trauma.

Short version of title

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Rahmanou. Maternal age and obstetric trauma. Am J Obstet Gynecol 2016

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We wish Figure 4 to be published in the print issue of the Journal.

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ABSTRACT
Background
There are number of poor birth outcomes with advancing maternal age. While
there is some evidence of a higher risk of trauma to obstetric anal sphincter

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and the levator ani muscle with advancing age, findings to date are
inconclusive.
Objectives

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The aim of this study was to assess the risk of pelvic floor injury using
translabial 3D/4D ultrasound relative to advancing maternal age in primiparous

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women after 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

Study Design

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levator hiatus.

This is a sub-analysis of a perinatal intervention trial conducted in a specialist

urogynecology referral unit at two tertiary units.

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All primiparous women with singleton birth at term underwent 3D/4D translabial

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pelvic floor ultrasound both ante- and post-natally for assessment of the
obstetric trauma including Levator ani muscle avulsion, hiatal over-distension
to 25 cm2 or more, and obstetric anal sphincter injuries.
Multivariate logistic regression analysis was performed to examine the
association between maternal age and obstetric trauma diagnosed on 3D/4D
translabial ultrasound. Multiple confounders were included, and the most
significant (Forceps and Vacuum delivery) were used for probability modeling.

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Results
Of 660 women recruited for the original study, a total of 375 women who had a
vaginal delivery with complete datasets were analyzed. 174 women (46.4%)
showed evidence of at least one form of major pelvic floor trauma.

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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 (p=0.003). The probability of

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any type of trauma appears to be substantially higher for forceps delivery.

Vacuum delivery appears to increase the risk of obstetric anal sphincter

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injuries, but not of levator avulsion.

Conclusions

There is a significant association between the risk of major pelvic floor injury

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and increasing maternal age at first delivery.

Keywords: hiatal over-distension, levator ani avulsion, maternal age, Obstetric

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anal sphincter injuries, Obstetric trauma, Translabial 3D/4D Ultrasound.

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Introduction
There has been a marked increase in the age of women giving birth to their
first child in developed countries1-4. Pregnancy at an advanced maternal age is
associated with a higher risk of adverse outcomes such as miscarriage, pre-

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eclampsia, small for gestational age, gestational diabetes mellitus5,6 and

emergency operative deliveries7-9.

However, there is limited information in the literature regarding any association

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between advancing maternal age at the time of vaginal delivery with risk of
maternal obstetric trauma. A retrospective study utilizing 3D/4D translabial

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ultrasound in women with pelvic floor dysfunction, showed a higher risk of

levator ani muscle (LAM) injuries ('avulsion') in mothers who had their first child
at a more advanced age10. However, most mothers involved in the study were
multiparous. Therefore, it is not clear which delivery might have caused the

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injury diagnosed many years later.

In retrospective epidemiological studies of primiparous women, older mothers

appear to have a higher risk of obstetric anal sphincter injuries (OASIS)

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compared to younger mothers11,12. While there is some suggestion of a higher

risk of OASIS and LAM injuries in older mothers having their first child, to date

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this has not been conclusively demonstrated in a prospective study examining

the effects of advanced maternal age on obstetric trauma.
This study is a sub-analysis of a multicenter randomized controlled trial, the
'Epi-No trial', which tested an antenatal intervention for its effect on postnatally
diagnosed obstetric trauma13. The Epi-No is a birth trainer device developed
to gradually stretch the vagina and perineum with the aim of reducing perineal
trauma14.
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The aim of this sub-analysis is to assess the risk of pelvic floor injury using
3D/4D ultrasound relative to advancing maternal age in primiparous women
after singleton vaginal delivery at term. We aim to define statistical association
between maternal age and sonographically diagnosed defects of the external

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anal sphincter, levator ani muscle avulsion and irreversible hiatal over-

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distension in the context of both simple and operative vaginal deliveries.

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Materials and Methods

This study is a sub-analysis of a prospective perinatal interventional trial at two
tertiary obstetric units in Australia. Women in their first ongoing pregnancy in

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the third trimester were recruited between July 2007 and September 2013.
They all underwent a standardized interview, clinical examination including
International Continence Society (ICS) Pelvic Organ Prolapse Quantification

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(POPQ) assessment15 and a 3D/4D translabial pelvic floor ultrasound (TLUS),

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at 35 - 37 weeks of gestation and 3-6 months postpartum. The assessor at

postpartum follow-up was blinded to intrapartum data. Ultrasound volume
acquisition was performed using either a GE Voluson 730 Expert or E8 System
(GE Medical Systems, Zipf, Austria), with a 8-4MHz curved array volume
transducer, supine and after voiding, at rest, on maximum Valsalva maneuver

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(the best of at least three attempts) and on maximal pelvic floor muscle
contraction (PFMC)16. At least one volume data set was obtained on PFMC,
ensuring that the entire anal canal was included in the volume for the

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assessment of anal sphincter17. Ultrasound volume datasets were analyzed for

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levator avulsion, hiatal overdistension (microtrauma) and external anal

sphincter (EAS) integrity independently at a later date on a desktop personal
computer using the proprietary software GE Kretz 4D View version 10.0 (GE
Medical Ultrasound Kretz GmbH, Zipf, Austria) with the assessors blinded to all
clinical data.
Levator avulsion was diagnosed on tomographic ultrasound imaging (TUI) of
the pelvic floor at 2.5 mm inter slice interval incorporating slices 5 mm caudal

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to 12.5 mm cranial of the plane of minimal hiatal dimensions on volumes
obtained at maximal PFMC18. A dataset was rated positive for avulsion upon
observing an abnormal insertion of the puborectalis muscle on the inferior

mm cranial; i.e. slice 3-5 in Figure 1)19,20.

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pubic ramus in the three central slices (reference slice and the slices 2.5 to 5

Significant hiatal overdistension (microtrauma) was defined as a peripartum

increase in hiatal area on Valsalva of at least 20% resulting in a hiatal area of

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>=25cm2 ('ballooning') in the absence of levator avulsion21. The plane of

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minimal hiatal dimensions was identified in the midsagittal orthogonal plane,

where the distance between the hyperechogenic posterior aspect of the
symphysis pubis and hyperechogenic anterior border of the levator ani muscle,
just posterior to the anorectal muscularis, is shortest. Hiatal area was
measured in rendered volumes of 1-2 cm thickness containing this plane of

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minimal hiatal dimensions22.

External anal sphincter integrity was assessed utilizing volumes acquired on

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PFMC. A set of eight TUI slices in an oblique coronal plane was obtained
encompassing the entire EAS by tailoring the inter-slice interval to the

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individuals EAS length, from the level of the puborectalis muscle to the
subcutaneous part of EAS. A significant EAS defect is defined as the presence
of a gap of >=30 in its circumference, in at least four out of six central slices17.
The ultrasound data was analyzed against obstetric data retrieved from the
local maternity database. Statistical analysis was performed using Minitab v
16 (Minitab Inc., State College, PA, USA) and SAS v 9.3 (Cary CR: SAS
institute INC, USA). Logistic regression analysis was performed to determine
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the association between maternal age and risk of the three types of pelvic floor
damage as described above and also overall combinations of any three types
of injury. We adjusted for multiple confounders including gestational age at
delivery, body mass index (BMI), birth weight, head circumference and delivery

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mode. Confounders were selected on the basis of prior evidence and used for
full multivariate modelling. A backwards elimination approach was utilised, with

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covariates eliminated in order of lack of significance.23

A P<0.05 was considered statistically as significant. We did not undertake

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power calculations for this particular sub-analysis. As the intervention tested in

the parent trial (antenatal use of the Epi-No device) was shown to have no
effect on any of the tested outcome measures13, we felt justified to perform this
sub-analysis not just in the control arm but in the entire study population. The

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parent RCT was approved by the Sydney West and Sydney South Area Health
Service Human Research Ethics Committee (SWAHS HREC 07-022 and

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SSAHS HREC X09-0384).

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Results
Six-hundred and sixty nulliparous women carrying an uncomplicated singleton
pregnancy were recruited for the Epi-No trial, at mean gestation of 35.8 (SD

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0.75, range 31.6-37.6) weeks. A total of 498/660 women (75.5%) returned for a
follow-up appointment at a mean interval of 5 (SD 2.5, Range 1.8-24.3)
months. In five women, we were unable to retrieve ultrasound data sets or

Of the remainder, 112 (23%) women had a caesarean section,

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subjects.

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imaging was unsatisfactory, and delivery record data was missing in 6

leaving a total of 375 women who had a vaginal delivery for analysis. Mean
age was 30.5 (SD 5.1, range 18.8 42.5) years, mean Body Mass Index (BMI)
was 27.9 (range 18.0 -28.6) kg/m2 at time of recruitment, and mean gestation

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at delivery 39.7 (range 36.3- 42.2) weeks. Mean birth weight was 3.41 (range
2.2- 4.7) kg. 80% of the study group was Caucasian. Of those 375 women, 269
(72%) had a NVD, 69 (18%) had a vacuum extraction and 37(10%) had a

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Forceps delivery. Of those with vaginal delivery, 102 (27%) had a mediolateral
episiotomy. Mean length of first stage was 455 (SD 267, range 50-1720) min

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and mean second stage was 80 (SD 67, range 0-472) min.

Levator avulsion was diagnosed in 70/375 (18.7%), microtrauma in 48/375

(12.8%) and OASIS in 88/361 (24.4%; missing data in 14). One hundred and
seventy- four women (46.4%) showed evidence of at least one form of major
pelvic floor trauma. The associations between maternal age and different
forms of pelvic floor trauma on univariate analysis are summarized in Table 1.

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A backwards elimination approach was applied to a full multivariate model
comprising age, mode of delivery, group allocation, gestational age at delivery,
BMI, and head circumference giving a best subset model comprising only

latter remained significant at P= 0.0268.

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mode of delivery and age. The former was highly significant at P= 0.0002; the

The trial intervention was not a confounder for the relationship between age

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and injury and was ineffective in preventing any form of trauma13. The data
was sub-analyzed for each type of vaginal delivery and estimated probability of

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any major injury and each type of trauma as summarized in Figure 4.

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Comment
Obstetric pelvic floor trauma is very common in our population, affecting almost
half (46.4%) of vaginally parous primiparae seen at an average of 5 months
postpartum. Most of this type of trauma is never diagnosed, and therefore goes

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untreated. Advancing age is a major risk factor for multiple negative outcomes
in obstetrics5-8, and this also seems to be true for obstetric trauma identified
using translabial 4D ultrasound.

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With advancing maternal age at first delivery there appears to be an

incremental increase in risk of obstetric trauma during vaginal birth, with an

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Odds ratio of 1.064 for overall risk of injury for each year of age past age 18.
Therefore, for each added year of maternal age, the primiparas risk of
obstetric injury increases by a factor of 1.064 over the risk from the previous

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year. Using this model, a 40 year old nulliparous woman is at a 346% (1.064 to
the power of 20 years of age gap) higher risk of injury compared to an 20 year
old nulliparous woman. This is consistent with retrospective studies, both by

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magnetic resonance imaging24 and 4D pelvic floor ultrasound10 and with a

previous, much smaller prospective study by the senior author25. The

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probability of any type of trauma appears to be much greater for forceps

delivery, when compared to Vacuum and normal vaginal delivery, which also is
consistent with the literature26.

To our knowledge, this is the first prospective study assessing the risk of
obstetric trauma to levator ani and external anal sphincter in relation to
advancing maternal age in singleton term vaginal delivery. We used 4D TLUS

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imaging rather than clinical assessment in order to optimize detection of
obstetric trauma. Levator tears or 'avulsions' are rarely diagnosed in Delivery
Suite27, while anal sphincter trauma is thought to be frequently overlooked28.

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However, the fact that this data is the experience of two individual units in
Australia should be acknowledged as a limitation as it may not represent
obstetric practice around the globe. In New South Wales of Australia where the

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study took place, the rate of forceps delivery in 2013 was on average 4.6%29.
In comparison the rate in England for the same year was on average 7%30

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while Forceps is uncommon in Scandinavia, the US and Germany26. Since

obstetric trauma is likely to be strongly dependent on Forceps rate, our results
may not apply to other jurisdictions. In addition, LAM morphology and biometry
seems to vary from one ethnicity to another31,32. The fact that our study

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population was largely Caucasian in ethnicity limits the applicability of our

results and conclusions to other ethnic backgrounds.

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Furthermore, it should be mentioned that this study describes an association

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between maternal age and incidence of sonographically diagnosed obstetric

trauma, but it does not provide any information on the cause(s) of this
association. Equally, as the prevalence of symptoms associated with maternal
birth trauma (anal incontinence and prolapse) is low at the time point
investigated by us, we were unable to analyze such symptoms due to a lack of
power.

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It is well known that the prevalence of operative vaginal delivery increases with
advancing maternal age8,9. However, the rise in obstetric trauma with
increasing age clearly cannot solely be blamed on a higher prevalence of
instrumental delivery in older women. On controlling for delivery mode in

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multivariate modelling, the association between trauma and maternal age

remained significant, suggesting that this association is not exclusively (or
even predominantly) explained by the increasing prevalence of operative

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delivery with age. Even women with normal delivery had a higher risk of injury
with advancing age in this study. One possible explanation for this

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phenomenon may be the reduced elasticity of tissue with advancing age33,

likely as a result of compromised elastic fibre function. Another explanation in
the case of levator trauma may be reduced bone density in older primiparae as
this may impair the biomechanical properties of the rather unusual muscle-

'enthesis'.24

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bone interface between os pubis and puborectalis muscle, a so-called

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In the opinion of the authors, this data may well have implications for the

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management and counseling of women having their first vaginal delivery,

especially those over the age of 35. The older the patient is at the time of her
first birth, the greater the potential long-term deleterious effects of vaginal
childbirth are likely to be, and the smaller will be the potential negative
consequences of Caesarean delivery, given that future pregnancies are less
likely. If instrumental delivery is required (as it is more likely to be in this age
group), vacuum delivery should be encouraged as much as possible in order to
avoid major obstetric trauma. Current practices and national guidelines aiming
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to reduce Caesarean Section rates fail to consider the impact operative
delivery may have on the pelvic floor, especially for first time mothers of
advanced maternal age (>35)34,35.
Apart from immediate complications following obstetric injury such as

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hemorrhage, anal sphincter and vaginal tears, urinary retention and

psychological trauma,36 in the long term these women are at an increased risk
of developing pelvic organ prolapse (POP)37,38 and recurrent POP even after

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surgical correction.39,40

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In conclusion, there is a significant increase in the risk of pelvic floor injury with
increasing age at first vaginal delivery, which may be secondary to age related
changes in tissue biomechanics. This is independent of delivery mode. The
increased risk of obstetric trauma should be considered in women having their

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first delivery at advanced age.

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Acknowledgement

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The authors would like to thank Andrew Martin, PhD, Senior Biostatistician at
Sydney Medical School Nepean, University of Sydney, for his help with
statistical analysis.

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Table

Table 1: Risk of obstetric trauma with maternal age

P value

RI
PT

95% Confidence
Intervals
1.021 1.108

0.003

Levator ani avulsion (n=375)

1.050

0.996 1.108

0.07

Hiatal over-distension (n=375)

1.058

1.0 1.125

0.07

OASIS* (n=361)

1.038

SC

Overall Injury* (n=361)

Odds Ratio
(per year of
Age)
1.064

0.13

M
AN
U

0.989 1.089

AC
C

EP

TE
D

(*lower number due to missing / US volume of insufficient quality for assessment of external
anal sphincter) ; OASIS, obstetrics anal sphincter injuries.

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Figure Legends
Figure 1. Tomographic ultrasound imaging of the puborectalis muscle:
Complete right sided levator avulsion on tomographic ultrasound imaging (TUI)

RI
PT

of the puborectalis muscle indicated by
. The volume data used for this
representation was acquired translabially in the midsagittal plane, on pelvic
floor muscle contraction.

SC

Figure 2. Translabial Ultrasound for the assessment of hiatal dimensions

on Valsalva: Hiatal overdistension (microtrauma) as seen in the midsagittal

M
AN
U

plane (left, A) and a rendered volume in the axial plane (right, B) in a patient
with significant cystocele. (A) The plane of minimal dimensions is shown by
arrows between symphysis pubis (SP) and the anorectal angle in the
midsagittal plane at maximum valsalva. (B) The levator hiatus is outlined by

levator hiatus.

TE
D

the dotted line. SP = symphysis pubis, C = cystocele, L = levator ani, LH =

EP

Figure 3. Assessment of the external anal sphincter on Tomographic

ultrasound imaging. A significant external anal sphincter (EAS) defect is

AC
C

diagnosed in the presence of a gap in its circumference of >=30 degree in at

least four tomographic ultrasound imaging (TUI) slices bracketing the EAS.
This defect is indicated by angle measurements, which are all >30 degrees.

Figure 4. Estimated probability of any major injury and each type of

trauma: Estimated probability of A) Any major injury B) Levator ani avulsion C)

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Hiatal over-distension and D) OASIS, as a function of age for each mode of

AC
C

EP

TE
D

M
AN
U

SC

RI
PT

vaginal delivery.

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EP

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D

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PT

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