Ultrasound Obstet Gynecol 2010; 35: 583588

Published online 18 January 2010 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.7563

Three-dimensional ultrasound of the pelvic floor 2 days after

first delivery: influence of constitutional and obstetric factors
A. FALKERT, E. ENDRESS, M. WEIGL and B. SEELBACH-GOBEL
Krankenhaus Barmherzige Bruder Frauenklinik St. Hedwig, Department of Obstetrics and Gynecology, University of Regensburg,
Regensburg, Germany

K E Y W O R D S: 3D ultrasound; delivery mode; female pelvic floor; levator ani muscle

ABSTRACT Conclusions Pelvic floor imaging by 3D ultrasound is

Objectives Morphological changes of the pelvic floor
during pregnancy and delivery can be visualized by three-
dimensional (3D) perineal ultrasound. The aim of this
study was to compare biometric measurements of the
levator ani muscle according to maternal constitutional
factors, delivery mode and size of the baby immediately
after the first delivery.
Methods In this prospective observational study, 130
primiparae were recruited (all of them Caucasians with
singleton pregnancy and cephalic presentation). A 3D
perineal ultrasound scan was performed on the second day
after delivery with standardized settings. Volumes were
obtained at rest and on Valsalva maneuver, and biometric
measurements of the levator hiatus were determined in
the axial plane. Different obstetric and constitutional
parameters were obtained from our clinical files.
Results All biometric measurements of the levator hiatus
were significantly greater in the vaginal delivery group
than in the Cesarean section group (P < 0.001), whereas
subgroup analysis within the vaginal (spontaneous vs.
operative vaginal) and Cesarean (primary vs. secondary)
delivery groups did not show statistically significant
differences. There was no demonstrable influence of
maternal constitutional factors (age, body mass index
(BMI)) or different obstetric parameters (length of
second stage of labor, episiotomy, maternal injuries) on
levator hiatus size postpartum, even in subgroups that
delivered vaginally. Women with de novo postpartum
stress incontinence showed a significantly higher mean
levator hiatus transverse diameter and larger hiatal area
on Valsalva maneuver (P < 0.05). There was also a
positive but very weak correlation between the newborns
head circumference and hiatal dimensions at Valsalva
maneuver (P < 0.05).
easily accessible even on the first days after delivery
and can provide useful information on morphological
changes of the levator ani muscle. In our study,
women with vaginal or operative vaginal delivery had
a significantly larger hiatal area and transverse diameter
than women who delivered by Cesarean section. Maternal
constitutional factors (BMI, age) and duration of second
stage of labor had no influence on the biometric
measurements of hiatal area, whereas weight and head
circumference of the baby showed a positive correlation
with area of the levator hiatus. Copyright 2010 ISUOG.
Published by John Wiley & Sons, Ltd.
INTRODUCTION
Visualization of morphological changes of the pelvic floor
during pregnancy and delivery has been the focus of
research in recent years. Morphological changes in the
area of the levator hiatus may have clinical significance
in the subsequent development of urinary incontinence
and pelvic organ prolapse1,2 . The levator ani muscle is
thought to play a significant role in the pathogenesis of
these highly prevalent conditions and it is estimated that
parous women have an 11.8% lifetime risk (by age 80) of
undergoing surgical treatment for one or other of these3 .
Pregnancy and childbirth are frequently cited as major
etiological factors, and different obstetric parameters
(e.g. length of second-stage labor, birth weight, mode of
delivery) have been shown to be additional risk factors4,5 .
A potential protective effect of Cesarean section could not
be verified in long-term studies, suggesting that pregnancy
itself (especially the first one) causes pathological changes
to the pelvic floor, regardless of the mode of delivery6 8 . It
has been suggested that the strain of the gravid uterus und

Correspondence to: Dr A. Falkert, Krankenhaus Barmherzige Bruder, Frauenklinik St. Hedwig, Steinmetzstrasse 1-3, D-93049 Regensburg,
Germany (e-mail: andreas.falkert@barmherzige-regensburg.de)
Accepted: 19 June 2009

Copyright 2010 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER
584 Falkert et al.

hormonal changes during pregnancy lead to connective
tissue remodeling and disruption of normal pelvic floor
function, while additional disruption may result during
vaginal delivery from traumatic damage (primarily by
vacuum or forceps extraction)9 .
Changes in the area of the levator hiatus as a
result of the first delivery may, therefore, have clinical
significance for the development of pelvic floor problems
at a younger age. Until recently, magnetic resonance
imaging (MRI) was the only imaging method capable
of assessing the levator ani muscle. However, cost, access
and contraindications (e.g. metallic implants) may limit
the scope for adoption of this diagnostic method in clinical
practice.
For more than 10 years, translabial or perineal
two-dimensional ultrasonography has been used to
assess bladder neck position and movement during
Valsava maneuver and cough10,11 . Three-dimensional
(3D) ultrasound has the advantage of multiplanar view
and direct imaging of the entire levator hiatus (axial
plane), previously the domain of MRI12 . Ultrasonography
is clinically more convenient, easily accessible, and
can safely be used throughout pregnancy and the
puerperium. The techniques for acquiring and interpreting
the ultrasound data can easily be learnt by interested
clinicians, and offline analysis of the stored 3D-volume
is possible at any time. Because four-dimensional (4D)
ultrasonography involves real-time imaging, the levator
hiatus can be followed during maneuvers and provide
qualitative and quantitative information on muscle
function. Regardless of any methodological differences,
it seems that both ultrasound and MRI are highly
repeatable and reliable, as shown in the literature on
the subject13,14 .
The aim of this study was to compare biometric
measurements of the levator ani muscle according to
maternal constitutional factors, delivery mode and size of
the baby immediately after the first delivery.
48-MHz curved array 3D/4D ultrasound transducer
(RAB 4-8p/obstetric) was used. The probe was covered
with a sterile latex-free condom and placed on the
perineum in the sagittal plane. The field of view
angle was set to a maximum of 70 in the sagittal
plane, the volume aquisition angle to 85 in the axial
plane, and preset obstetrics 2./3. trimester was used.
Analysis of the stored volumes was conducted offline
by one experienced investigator and measurements were
performed in the axial plane as described by Dietz
et al.12 . In addition, 3D render-mode images were made
(Figure 1).
The following parameters were assessed for this
study: maximum diameters of the levator hiatus
(anteroposterior and transverse) at rest and on Val-
salva maneuver (Figure 2); area of the levator hia-
tus at rest and on Valsalva (Figure 3); and pubo-
visceral muscle thickness (left and right of the rec-
tum) at the level of maximum muscle thickness
(Figure 2).
Statistical analysis was performed after normality
testing (KolmogorovSmirnov) using SPSS 16.0 (SPSS,
Chicago, IL, USA). Pearsons correlation coefficient (r)
was used to compare normally distributed continuous
variables. Mean values were compared by Fishers
ANOVA (for more than two groups) or Students t-test
(for two groups). P < 0.05 was considered statistically
significant.

METHODS
The study was performed at a German tertiary perinatal
center with 2100 deliveries per year. A total of 130
primiparae were recruited over an 8-month period,
all of them volunteers, and informed consent was
given in each case. Local ethics committee approval
was sought and obtained. The patients underwent a
semi-structured interview about history and continence
status. Different obstetric parameters (maternal body
mass index (BMI), age, mode of delivery, duration of
second stage of labor, episiotomy, maternal injuries,
birth weight and head circumference) were obtained
from the complete clinical files. All ultrasound volumes
were acquired on the second day after delivery by two
experienced sonographers. Two 3D-volumes (one at rest,
one on Valsalva maneuver) were recorded in the supine
position after voiding, automatic image acquisition taking
about 4s each. A GE Voluson 730 expert ultrasound Figure 1 Axial-view render-mode ultrasound image of female
system (GE Healthcare, Munich, Germany) with a pelvic floor on second day after delivery.

Copyright 2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2010; 35: 583588.
3D ultrasound of pelvic floor after first delivery
Figure 2 Two-dimensional ultrasound image (axial view) of the
levator hiatus showing biometric measurements of transverse
diameter (calipers 3), anteroposterior diameter (calipers 4) and
thickness (calipers 1 and 2) of the levator ani muscle.
RESULTS
A total of 130 primiparae, all of them Caucasians, under-
went a 3D-ultrasound assessment of the pelvic floor on
the second day after delivery. Satisfactory volume datasets
and delivery data could be obtained in all cases. The study
included only singleton pregnancies with cephalic presen-
tation. Mean age was 29.8 (range, 1642) years and
mean BMI was 23.2 (range, 1740) kg/m2 . Mean gesta-
tional age at delivery was 39.3 (range, 3442) weeks.
Thirty-nine of the 130 women (30.0%) were deliev-
ered by Cesarean section (11 by elective Cesarean), 77
(59.2%) had a spontaneous vaginal delivery, and 14
women (10.8%) had an instrumental vaginal delivery. At
the time of examination, none of the participants had
symptoms of prolapse or fecal incontinence, but eight
women (6.2%) reported de novo stress urinary inconti-
nence. For the purpose of analysis, no differentiation was
made between the different types of vaginal delivery owing
to the small numbers that would have resulted in each
category. The median duration of second stage of labor
in the group of women who delivered vaginally was 89.1
(range, 7278) min and an episiotomy was performed in
46.9% of all vaginal deliveries. The mean birth weight
of the babies was 3343 (range, 17954930) g and mean
head circumference was 34.7 (range, 3039) cm.
Copyright 2010 ISUOG. Published by John Wiley & Sons, Ltd.
585
Figure 3 Two-dimensional ultrasound image (axial view) showing
biometric measurements of the hiatal area.
Table 1 shows the average biometric measurements of
the levator ani muscle according to the different modes of
delivery. All biometric measurements of the levator hiatus
were significantly greater in the vaginal delivery group
than in the Cesarean section group, whereas subgroup
analysis within the vaginal (spontaneous vs. operative
vaginal) and Cesarean (primary vs. secondary) delivery
groups did not reach significance (Figure 4). There was no
demonstrable influence of maternal constitutional factors
(age, BMI) or different obstetric parameters (length of
second-stage labor, episiotomy, maternal injuries) on the
levator hiatus distension postpartum, even in the subgroup
that delivered vaginally.
The biometric measurements with regard to absent or
reported stress urinary incontinence are summarized in
Table 2. The mean levator hiatus transverse diameter and
the hiatal area on Valsalva maneuver were significantly
higher in the small group of women with urinary
incontinence (n = 8) than in the group of continent
women (49 vs. 42 mm (P < 0.05) and 28 vs. 21 cm2 (P <
0.01), respectively). There was a very weak but significant
correlation between the childs head circumference and
the hiatal distension (axial diameter, hiatal area) during
Valsalva maneuver (P < 0.05 in each case), but there
were no significant differences between mean birth weight
and head circumference in the group of incontinent vs.
continent women. Figure 5 shows the correlation of hiatal
area on Valsalva and head circumference of the newborn,
Ultrasound Obstet Gynecol 2010; 35: 583588.
586 Falkert et al.

P < 0.001
40.0
45 NS

40 37.5
Hiatal area on Valsalva (cm2)

35

Head circumference (cm)

30
NS 35.0
25

20
32.5
15

10
30.0
5

0
Vaginal Operative Primary Secondary 27.5
vaginal Cesarean Cesarean
Mode of delivery
25.0
Figure 4 Hiatal area on Valsalva maneuver according to mode of 0 10 20 30 40 50
delivery. The boxes represent median and 25th and 75th percentiles, Hiatal area on Valsalva (cm2)
the whiskers indicate the 5th and 95th percentiles and outliers are
marked by circles. NS, non-significant difference. Statistical Figure 5 Correlation of neonatal head circumference and maternal
comparisons by Students t-test. hiatal area on Valsalva maneuver; r2 linear = 0.04.

and Figure 6 shows the correlation between birth weight

and hiatal area at Valsalva.
DISCUSSION
This study demonstrates clear differences in postpartum
levator hiatus dimensions according to the different modes
of delivery and fetal proportions in primiparae. Women
with vaginal or operative vaginal delivery had significantly
larger hiatal dimensions than did women who delivered
by Cesarean section, especially during Valsalva maneuver.
No significant differences could be found in subgroup
analysis (vaginal vs. operative vaginal and primary vs.
secondary Cesarean). However, a relationship between
dimensions of the levator hiatus and the length of second-
stage labor or other obstetric parameters could not be
found in our study. The small group of women with
stress urinary incontinence on the first days after delivery
had a significantly larger hiatal area and pelvic floor
hypermobility than did the women without symptoms.
There is limited information on sonomorphologic changes
of the female pelvic floor after delivery obtained by 3D
ultrasonography. The association of increased bladder
neck mobility and vaginal delivery has been previously
noted by several authors15 17 . Dietz et al.18 reported
negative effects on the fascial supports of all three
pelvic compartments after vaginal delivery compared
with Cesarean section. This effect seems to be more
distinct in women delivered by forceps or vacuum
extraction. Avulsion of the pubovisceral muscle from
the pelvic sidewall is reported to occur in 1030% of
all vaginal deliveries19,20 and has a marked effect on
hiatal dimensions, distensibility and contractility, which
may equally predispose to prolapse. Levator avulsion
can be verified by palpation, speculum examination and
ultrasound imaging21,22 . In our study, a detailed search for
levator avulsion was not performed owing to the limited

Table 1 Biometric parameters of the levator hiatus muscle according to mode of delivery

Mode of delivery

Operative Primary Secondary

Vaginal vaginal Cesarean Cesarean
Parameter (n = 77) (n = 14) (n = 11) (n = 28) P*

Levator thickness (mm) 10.8 1.7 10.9 2.1 9.5 2.1 8.9 1.7 < 0.001
Hiatal diameter (transverse) at rest (mm) 42.0 5.5 42.4 6.9 38.6 6.8 36.0 3.9 < 0.001
Hiatal diameter (anteroposterior) at rest (mm) 72.0 8.2 70.9 7.0 58.2 5.3 59.5 5.8 < 0.001
Hiatal area at rest (cm2 ) 22.2 4.7 22.6 6.5 16.2 3.2 15.5 2.8 < 0.001
Hiatal diameter (transverse) on Valsalva (mm) 44.9 6.0 45.3 7.8 38.2 4.7 37.6 5.1 < 0.001
Hiatal diameter (anteroposterior) on Valsalva (mm) 72.8 8.3 72.1 6.4 58.5 6.8 59.5 7.4 < 0.001
Hiatal area on Valsalva (cm2 ) 24.3 5.6 24.5 5.9 16.2 2.7 16.1 3.3 < 0.001

H (area) (area on Valsalva area at rest) (cm2 ) 2.1 3.7 1.8 4.1 0.0 1.7 0.6 1.9 NS

Values are mean SD. *Fishers ANOVA. NS, not significant.

Copyright 2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2010; 35: 583588.
3D ultrasound of pelvic floor after first delivery
Table 2 Biometric parameters of the levator hiatus muscle according to presence or absence of urinary incontinence
Parameter
Levator thickness (mm)
Hiatal diameter (transverse) at rest (mm)
Hiatal diameter (anteroposterior) at rest (mm)
Hiatal area at rest (cm2 )
Hiatal diameter (transverse) on Valsalva (mm)
Hiatal diameter (anteroposterior) on Valsalva (mm)
Hiatal area on Valsalva (cm2 )

H (area) (area on Valsalva area at rest) (cm2 )
Values are mean SD. *Students t-test. NS, not significant.
5000
4500
4000
Birth weight (g)
3500
3000
2500
2000
1500
1000
0 10 20 30 40
Hiatal area on Valsalva (cm2)
Figure 6 Correlation of birth weight and maternal hiatal area on
Valsalva maneuver; r2 linear = 0.031.
image quality immediately after delivery. However,
levator avulsion is not the only mechanism by which
pelvic floor muscle function and pelvic organ support
may be impaired. Possible explanations for traumatic
pathogenesis in pelvic tissue also include alterations in
the matrix of connective tissue and damage to the pelvic
fascia, which may lead to a loss of contractility of the
levator ani complex23 25 . This may arise as a result of
damage to the muscle from distension, obstetric trauma or
neuropraxia of the pudendal nerve26,27 . All these effects
are likely to occur in women delivered by Cesarean
section, but statistically less commonly. Also pre-existing
constitutional differences in the biomechanical properties
of the pelvic floor and the connective tissue may be a cause
of morphologic changes during pregnancy and delivery28 .
Several authors have reported that joint hypermobility
or striae distensae may be early markers for stress urinary
incontinence in later life29,30 . Different collagen types are
likely to produce different tissue biomechanical properties
Copyright 2010 ISUOG. Published by John Wiley & Sons, Ltd.
587
Urinary incontinence
Present (n = 8) Absent (n = 122) P*
11.4 2.7 10.2 1.9 NS
43.0 7.1 40.3 5.9 NS
70.9 9.1 67.8 9.4 NS
23.2 5.3 20.1 5.3 NS
48.6 7.7 42.4 6.6 < 0.05
74.6 11.5 68.3 9.7 NS
28.3 8.6 21.4 5.8 < 0.01
5.1 5.2 1.3 3.1 NS
that influence both the likelihood of progress in labor
and the subsequent prolapse and stress incontinence31,32 .
If a womans constitutional connective tissue type does
influence the relative likelihood of normal progression
in labor, then it may be acting as a cofounder, and the
mode of delivery may not be causative in determining
subsequent pelvic floor dysfunction33 .
In conclusion, this study demonstrates that dimensions
of the female pelvic floor can easily be assessed
immediately after the first delivery by 3D ultrasound. In
our opinion, this easily accessible diagnostic tool may help
to identify young mothers with a high risk for pelvic floor
dysfunction in later life. The correlation of pevic floor
problems 1 year after delivery and hiatal measurements
immediately after the first delivery is a subject of current
studies at our unit.
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