Delivery mode and the risk of levator muscle avulsion: a meta-analysis
Abstract
Introduction and hypothesis Female pelvic organ prolapse (POP) is a common condition, with a lifetime risk for surgery of 10-20%. Pregnancy and childbirth are the commonest modifiable risk factors for POP, and avulsion of the levator ani muscle is likely to be an etiological factor. Avulsion is more common in instrumental delivery. However, we were unable to identify a meta-analysis on this issue. Our aim was to perform a systemic review and quantitative meta-analysis of the prevalence of avulsion relative to delivery mode.Methods Four electronic databases (MEDLINE, PubMed, Embase, and Google Scholar) were searched for studies published between 1991 and 1 October 2018 without language restrictions.Results Twenty studies met inclusion criteria, and 14 were prospective. Seventeen used sonographic techniques; three were magnetic resonance (MR) studies. For this review, three comparisons were performed: forceps vs. vacuum (9 studies), forceps vs. normal vaginal delivery (NVD) (12 studies), and vacuum vs. NVD (12 studies). The first meta-analysis showed an increased risk for avulsion following forceps compared with vacuum, with an odds ratio (OR) of 4.57 and confidence interval (CI) 3.21-6.51, p < 0.001. The second showed an increased risk for avulsion following forceps compared with NVD, with an OR of 6.94 (4.93-9.78), p < 0.001. The third showed no significant increased risk for avulsion following vacuum compared with NVD, with an OR of 1.31 (1.00-1.72), p = 0.051.Conclusions Forceps is a strong risk factor for avulsion, with an OR of 6.94 (4.93-9.78) compared with NVD and an OR of 4.57 (3.21-6.51) compared with vacuum birth.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Several studies outside the scope of this systematic review have identified forceps delivery as a risk factor for levator injury.
“several studies outside the scope of this systematic review have identified forceps delivery as a risk factor for levator injury.”
From Risk factors for primary pelvic organ prolapse and prolapse recurrence: an updated systematic review and meta-analysis (2022) · cites this paper as [49]
A study in Black South African women showed significant alterations in postpartum levator hiatal distensibility, with more pronounced effects in women after vaginal delivery, whereas cesarean section was found to be protective.
“A study conducted in Black South African women showed significant alterations in postpartum levator hiatal distensibility, with more pronounced effects in women after vaginal delivery,28 whereas cesarean section was found to be protective.29”
From Association Between Mode of Delivery and Levator Ani Muscle Abnormalities on 4D Transperineal Ultrasound at 6 Weeks Postpartum (2026) · cites this paper as [29]
Cites
Measuring inconsistency in meta-analyses
Higgins, J. P. T., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003) · BMJ · doi:10.1136/bmj.327.7414.557 · Cited by 63,139 · see citing works
Bias in meta-analysis detected by a simple, graphical test
Egger, M., Smith, G. D., Schneider, M., & Minder, C. (1997) · BMJ · doi:10.1136/bmj.315.7109.629 · Cited by 56,722 · see citing works
Meta-analysis in clinical trials
DerSimonian, R., & Laird, N. (1986) · Controlled Clinical Trials · doi:10.1016/0197-2456(86)90046-2 · Cited by 39,552 · see citing works
Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence
OLSEN, A., SMITH, V, BERGSTROM, J., COLLING, J., & CLARK, A. (1997) · Obstetrics & Gynecology · doi:10.1016/s0029-7844(97)00058-6 · Cited by 3,335 · see citing works
A Fail-Safe N for Effect Size in Meta-Analysis
Orwin, R. G. (1983) · Journal of Educational Statistics · doi:10.2307/1164923 · Cited by 2,064 · see citing works
Lifetime Risk of Undergoing Surgery for Pelvic Organ Prolapse
Smith, F. J., Holman, C. D. J., Moorin, R. E., & Tsokos, N. (2010) · Obstetrics & Gynecology · doi:10.1097/aog.0b013e3181f73729 · Cited by 822 · see citing works
A Fail-Safe N for Effect Size in Meta-Analysis
Orwin, R. G. (1983) · Journal of Educational Statistics · doi:10.3102/10769986008002157 · Cited by 562 · see citing works
Levator Trauma After Vaginal Delivery
Dietz, H. P., & Lanzarone, V. (2005) · Obstetrics and Gynecology · doi:10.1097/01.aog.0000178779.62181.01 · Cited by 555 · see citing works
Self-citationLevator trauma is associated with pelvic organ prolapse
Dietz, H., & Simpson, J. (2008) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/j.1471-0528.2008.01751.x · Cited by 515 · see citing works
Self-citationObstetric Factors Associated With Levator Ani Muscle Injury After Vaginal Birth
Kearney, R., Miller, J. M., Ashton‐Miller, J. A., & DeLancey, J. O. L. (2006) · Obstetrics and Gynecology · doi:10.1097/01.aog.0000194063.63206.1c · Cited by 457 · see citing works
Ultrasound imaging of the pelvic floor. Part II: three‐dimensional or volume imaging
Dietz, H. P. (2004) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.1072 · Cited by 399 · see citing works
Self-citationIntrapartum risk factors for levator trauma
Shek, K., & Dietz, H. (2010) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/j.1471-0528.2010.02704.x · Cited by 359 · see citing works
Self-citationPelvic floor disorders 5-10 years after vaginal or cesarean childbirth
Handa, V. L., Blomquist, J. L., Knoepp, L. R., Hoskey, K. A., McDermott, K. C., & Muñoz, A. (2011) · Obstetrics & Gynecology · doi:10.1097/aog.0b013e3182267f2f · Cited by 345 · see citing works
Gyhagen, M., Bullarbo, M., Nielsen, T., & Milsom, I. (2012) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.12020 · Cited by 306 · see citing works
On the Biomechanics of Vaginal Birth and Common Sequelae
Ashton‐Miller, J. A., & DeLancey, J. O. L. (2009) · Annual Review of Biomedical Engineering · doi:10.1146/annurev-bioeng-061008-124823 · Cited by 296 · see citing works
Quantification of major morphological abnormalities of the levator ani
Dietz, H. P. (2007) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.3951 · Cited by 268 · see citing works
Self-citationValsky, D. V., Lipschuetz, M., Bord, A., Eldar, I., Messing, B., Hochner‐Celnikier, D., Lavy, Y., Cohen, S. M., & Yagel, S. (2009) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2009.03.028 · Cited by 207 · see citing works
DeLancey, J. O. L. (2002) · American Journal of Obstetrics and Gynecology · doi:10.1067/mob.2002.125733 · Cited by 205 · see citing works
Symptomatic Pelvic Organ Prolapse at Midlife, Quality of Life, and Risk Factors
Fritel, X., Varnoux, N., Zins, M., Breart, G., & Ringa, V. (2009) · Obstetrics & Gynecology · doi:10.1097/aog.0b013e3181985312 · Cited by 197 · see citing works
Brækken, I. H., Majida, M., Engh, M. E., Dietz, H. P., Umek, W. H., & Bø, K. (2007) · International Urogynecology Journal · doi:10.1007/s00192-007-0408-7 · Cited by 162 · see citing works
Self-citationAbdel-fattah, M., Familusi, A., Fielding, S., Ford, J., & Bhattacharya, S. (2011) · BMJ Open · doi:10.1136/bmjopen-2011-000206 · Cited by 139 · see citing works
Incidence and lifetime risk of pelvic organ prolapse surgery in Denmark from 1977 to 2009
Lowenstein, E., Ottesen, B., & Gimbel, H. M. (2014) · International Urogynecology Journal · doi:10.1007/s00192-014-2413-y · Cited by 132 · see citing works
Albrich, S., Laterza, R. M., Skala, C., Salvatore, S., Koelbl, H., & Naumann, G. (2011) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/j.1471-0528.2011.03152.x · Cited by 123 · see citing works
Levator avulsion using a tomographic ultrasound and magnetic resonance–based model
Zhuang, R. R., Song, Y., Chen, Z. Q., Ma, M., Huang, H., Chen, J. H., & Li, Y. M. (2011) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2011.03.052 · Cited by 115 · see citing works
Prevalence of levator ani muscle injury in Chinese women after first delivery
Chan, S. S. C., Cheung, R. Y. K., Yiu, A. K. W., Lee, L. L. L., Pang, A. W. L., Choy, K. W., Leung, T. Y., & Chung, T. K. H. (2011) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.10132 · Cited by 106 · see citing works
Levator ani muscle avulsion during childbirth: a risk prediction model
van Delft, K. W. M., Thakar, R., Sultan, A. H., Schwertner-Tiepelmann, N., & Kluivers, K. B. (2014) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.12676 · Cited by 96 · see citing works
Does delayed child‐bearing increase the risk of levator injury in labour?
Dietz, H. P., & Simpson, J. M. (2007) · Australian and New Zealand Journal of Obstetrics and Gynaecology · doi:10.1111/j.1479-828x.2007.00785.x · Cited by 89 · see citing works
Self-citationMemon, H. U., Blomquist, J. L., Dietz, H. P., Pierce, C. B., Weinstein, M. M., & Handa, V. L. (2015) · Obstetrics and Gynecology · doi:10.1097/aog.0000000000000825 · Cited by 78 · see citing works
Self-citationKearney, R., Fitzpatrick, M., Brennan, S., Behan, M., Miller, J. M., Keane, D. P., O’Herlihy, C., & DeLancey, J. O. L. (2010) · International Journal of Gynecology & Obstetrics · doi:10.1016/j.ijgo.2010.05.019 · Cited by 76 · see citing works
Volløyhaug, I., Mørkved, S., Salvesen, Ø., & Salvesen, K. Å. (2015) · Ultrasound in Obstetrics & Gynecology · doi:10.1002/uog.14891 · Cited by 65 · see citing works
Status of the pelvic floor in young primiparous women
Durnea, C. M., O’Reilly, B., Khashan, A. S., Kenny, L. C., Durnea, U. A., Smyth, M. M., & Dietz, H. P. (2014) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.14711 · Cited by 62 · see citing works
Self-citationForceps: towards obsolescence or revival?
Dietz, H. P. (2015) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.12592 · Cited by 57 · see citing works
Self-citationChung, M. Y., Wan, O. Y., Cheung, R. Y. K., Chung, T. K. H., & Chan, S. S. C. (2014) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.14700 · Cited by 45 · see citing works
Garriga, J. C., Isern, A. P., Pons, M. E., Durán-Retamal, M., Fabregas, A. F., & Rodríguez‐Carballeira, M. (2011) · International Urogynecology Journal · doi:10.1007/s00192-011-1413-4 · Cited by 44 · see citing works
Low, L. K., Zielinski, R., Tao, Y., Gałecki, A. T., Brandon, C. J., & Miller, J. M. (2014) · Open Journal of Obstetrics and Gynecology · doi:10.4236/ojog.2014.46043 · Cited by 43 · see citing works
Valsky, D. V., Cohen, S. M., Lipschuetz, M., Hochner‐Celnikier, D., Daum, H., Yagel, I., & Yagel, S. (2016) · Journal of Ultrasound in Medicine · doi:10.7863/ultra.15.04032 · Cited by 40 · see citing works
Four‐dimensional sonographic evaluation of avulsion of the levator ani according to delivery mode
Garriga, J. C., Isern, A. P., Pons, M. E., Durán-Retamal, M., Fabregas, A. F., Rodríguez‐Carballeira, M., & Santamaria, I. J. (2011) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.10062 · Cited by 36 · see citing works
Modelling the likelihood of levator avulsion in a urogynaecological population
Dietz, H. P., & Kirby, A. C. (2010) · Australian and New Zealand Journal of Obstetrics and Gynaecology · doi:10.1111/j.1479-828x.2010.01157.x · Cited by 27 · see citing works
Self-citationDoes episiotomy protect against injury of the levator ani muscle in normal vaginal delivery?
Garriga, J. C., Pessarrodona, A., Rodríguez‐Carballeira, M., Hinojosa, L., Manrique, G., Márquez, A. L., & Macias, M. (2013) · Neurourology and Urodynamics · doi:10.1002/nau.22488 · Cited by 27 · see citing works
OC 09.05: Intrapartum predictors of pelvic floor trauma
Caudwell‐Hall, J., Atan, I. K., Martin, A. J., Rojas, R. A. G., Langer, S., Shek, C., & Dietz, H. P. (2014) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.13519 · Cited by 13 · see citing works
Self-citationJúnior, E. A., Freitas, R. C. M. D., Bella, Z. I. K. D. J. D., Alexandre, S. M., Nakamura, M. U., Nardozza, L. M. M., & Moron, A. F. (2013) · Revista Brasileira Ginecologia e Obstetrícia · doi:10.1590/s0100-72032013000300005 · Cited by 13 · see citing works
Vacuum-assisted vaginal delivery and levator ani avulsion in primiparous women
Michalec, I., Šimetka, O., Navrátilová, M., Tomanová, M., Gärtner, M., Šalounová, D., Procházka, M., & Kacerovský, M. (2015) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.3109/14767058.2015.1102223 · Cited by 10 · see citing works
OP34.05: Obstetric anal sphincter injury—how does a subsequent delivery affect long term outcome?
Eisenberg, V. H., Brecher, S. Y., Yodfat, I., Bitman, G., Achiron, R., ALCALAY, M., & Schiff, E. (2011) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.9572 · Cited by 9 · see citing works
OP34.06: The birthmark of instrumental deliveries
Eisenberg, V. H., Brecher, S. Y., Kalter, A., Achiron, R., Schiff, E., & ALCALAY, M. (2011) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.9573 · Cited by 7 · see citing works
Response to the letter to the editor by H.P. Dietz
Løwenstein, E., Ottesen, B., & Gimbel, H. M. (2015) · International Urogynecology Journal · doi:10.1007/s00192-015-2741-6 · Cited by 2 · see citing works
OP28.04: The prevalence of major birth trauma in Nepali women
Turel, F., Caagbay, D., & Dietz, H. P. (2017) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.17961 · Cited by 2 · see citing works
Self-citation
Flagged first, then by citations
Cited by
Sorted by citations
Schulten, S. F. M., Claas-Quax, M. J., Weemhoff, M., van Eijndhoven, H. W., van Leijsen, S. A., Vergeldt, T. F., IntHout, J., & Kluivers, K. B. (2022) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2022.04.046 · Cited by 245 · see citing works
“a direct link between forceps delivery and POP, several studies outside the scope of this systematic review have identified forceps delivery as a risk factor for levator injury.(49) In turn, on the basis of our results, levator defect is identified as a risk factor for primary POP.”
BackgroundBharucha, A. E., Knowles, C. H., Mack, I., Malcolm, A., Oblizajek, N. R., Rao, S. S. C., Scott, S. M., Shin, A., & Enck, P. (2022) · Nature Reviews Disease Primers · doi:10.1038/s41572-022-00381-7 · Cited by 117 · see citing works
Doumouchtsis, S. K., de Tayrac, R., Lee, J., Daly, O., Melendez-Munoz, J., Lindo, F. M., Cross, A., White, A. B., Cichowski, S. B., Falconi, G., et al. (2022) · International Urogynecology Journal · doi:10.1007/s00192-022-05397-x · Cited by 114 · see citing works
Pregnancy, labour and delivery as risk factors for pelvic organ prolapse: a systematic review
Cattani, L., Decoene, J., Page, A.-S., Weeg, N., Deprest, J., & Dietz, H. P. (2021) · International Urogynecology Journal · doi:10.1007/s00192-021-04724-y · Cited by 94 · see citing works
Self-citationInternational Urogynecological Consultation (IUC): pathophysiology of pelvic organ prolapse (POP)
Deprest, J. A., Cartwright, R., Dietz, H. P., Brito, L. G. O., Koch, M., Allen‐Brady, K., Manonai, J., Weintraub, A. Y., Chua, J. W. F., Cuffolo, R., et al. (2022) · International Urogynecology Journal · doi:10.1007/s00192-022-05081-0 · Cited by 56 · see citing works
Self-citationUltrasound imaging of maternal birth trauma
Dietz, H. P. (2021) · International Urogynecology Journal · doi:10.1007/s00192-020-04669-8 · Cited by 50 · see citing works
Self-citationLevator ani avulsion: a Systematic evidence review (LASER)
Rušavý, Z., Paymova, L., Kozerovsky, M., Veverkova, A. M., Kališ, V., Kamel, R., & Ismail, K. (2021) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.16837 · Cited by 45 · see citing works
Assisted vaginal birth in 21st century: current practice and new innovations
Bahl, R., Hotton, E. J., Crofts, J. F., & Draycott, T. J. (2023) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2022.12.305 · Cited by 44 · see citing works
Cattani, L., Neefs, L., Verbakel, J. Y. J., Bosteels, J., & Deprest, J. A. (2021) · International Urogynecology Journal · doi:10.1007/s00192-021-04723-z · Cited by 40 · see citing works
Ultrasound in the investigation of pelvic floor disorders
Dietz, H. P. (2020) · Current Opinion in Obstetrics & Gynecology · doi:10.1097/gco.0000000000000659 · Cited by 36 · see citing works
Self-citationPrevalence of levator ani avulsion in a multicenter study (PAMELA study)
Garriga, J. C., González, M. S., Rodríguez-Mias, N. L., Roda, O. P., Huguet, E., Mora, I., Girvent, M., Fernández, R., & Gich, I. J. (2020) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-020-05585-4 · Cited by 33 · see citing works
Levator avulsion and vaginal parity: do subsequent vaginal births matter?
Dietz, H. P., Walsh, C. A., Subramaniam, N., & Friedman, T. (2020) · International Urogynecology Journal · doi:10.1007/s00192-020-04330-4 · Cited by 24 · see citing works
Self-citationPostpartum ultrasound for the diagnosis of obstetrical anal sphincter injury
Bellussi, F., & Dietz, H. P. (2021) · American Journal of Obstetrics & Gynecology MFM · doi:10.1016/j.ajogmf.2021.100421 · Cited by 24 · see citing works
Self-citationDiagnosis of maternal birth trauma by pelvic floor ultrasound
Dietz, H. P. (2023) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2023.04.005 · Cited by 24 · see citing works
Self-citationAll or nothing? A second look at partial levator avulsion
Dietz, H. P., Shek, K. L., & Low, G. K. (2022) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.26034 · Cited by 20 · see citing works
Self-citationGarcía‐Mejido, J. A., Valero, I., Gálvez, I. M. A., Borrero, C., Fernández-Palacín, A., & Sainz‐Bueno, J. A. (2020) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.13852 · Cited by 18 · see citing works
Pipitone, F., Miller, J. M., & DeLancey, J. (2021) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.16760 · Cited by 18 · see citing works
Obstetric risk factors for levator ani muscle avulsion: A systematic review and meta-analysis
Wong, K. W., Okeahialam, N. A., Thakar, R., & Sultan, A. H. (2024) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2024.02.044 · Cited by 17 · see citing works
Forceps and vacuum: one goal, two entities
de Leeuw, J. W., & Daly, J. O. (2021) · International Urogynecology Journal · doi:10.1007/s00192-021-04866-z · Cited by 17 · see citing works
Halle, T. K., Stær-Jensen, J. E., Hilde, G., Bø, K., Engh, M. E., & Siafarikas, F. (2020) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.13878 · Cited by 16 · see citing works
A review of levator ani avulsion after childbirth: Incidence, imaging and management
Doxford‐Hook, E., Downey, C. L., Gibson, J., & Marsh, F. A. (2022) · Midwifery · doi:10.1016/j.midw.2022.103494 · Cited by 15 · see citing works
Contributing factors in forceps associated pelvic floor trauma
Caudwell‐Hall, J., Weishaupt, J., & Dietz, H. P. (2019) · International Urogynecology Journal · doi:10.1007/s00192-019-03869-1 · Cited by 13 · see citing works
Self-citationVaginal Birth and Pelvic Floor Trauma
Shek, K. L., & Dietz, H. P. (2019) · Current Obstetrics and Gynecology Reports · doi:10.1007/s13669-019-0256-8 · Cited by 13 · see citing works
Self-citationGeuens, S., Mivšek, A. P., & Gianotten, W. L. (2023) · Springer eBooks · doi:10.1007/978-3-031-18432-1 · Cited by 12 · see citing works
The pelvic floor during pregnancy and delivery: Can pelvic floor trauma and disorders be prevented?
Eggebø, T. M., & Volløyhaug, I. (2024) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.14875 · Cited by 10 · see citing works
Okada, Y., Nakagawa, C., Shigeta, M., Nomura, Y., Inoue, E., Ichizuka, K., & Yoshimura, Y. (2023) · Journal of Medical Ultrasonics · doi:10.1007/s10396-023-01369-w · Cited by 9 · see citing works
Doumouchtsis, S. K., de Tayrac, R., Lee, J., Daly, O., Melendez-Munoz, J., Lindo, F. M., Cross, A., White, A. B., Cichowski, S. B., Falconi, G., et al. (2022) · Continence · doi:10.1016/j.cont.2022.100502 · Cited by 10 · see citing works
Re: Green‐top Guideline 26 ‘Assisted vaginal birth’
Dietz, H. P., & Esegbona, G. (2020) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.16422 · Cited by 9 · see citing works
Self-citationGonzález‐Díaz, E., García‐Mejido, J. A., Martínez, A. M., Fernández‐Fernández, C., Cárdenes, I. O., Medina, M., Fernández‐Corona, A., Fernández-Palacín, A., & Sainz‐Bueno, J. A. (2019) · Neurourology and Urodynamics · doi:10.1002/nau.24167 · Cited by 8 · see citing works
Vaginal birth after Cesarean section and levator ani avulsion: a case–control study
Paymova, L., Švabík, K., Neumann, A., Kališ, V., Ismail, K. M., & Rušavý, Z. (2021) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.23629 · Cited by 8 · see citing works
Cárdenes, I. O., Dietz, H. P., García-Hernández, J. Á., González-Martín, J. M., Laseca-Modrego, M., & Martínez, A. M. (2021) · International Urogynecology Journal · doi:10.1007/s00192-021-04814-x · Cited by 8 · see citing works
Self-citationUltrasound examination of the pelvic floor during active labor: A longitudinal cohort study
Eggebø, T. M., Benediktsdóttir, S., Hjartardóttir, H., Salvesen, K. Å., & Volløyhaug, I. (2023) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.14620 · Cited by 7 · see citing works
The clinical application of transperineal ultrasound in urogynaecology
Retief, F., Paterson, F., Jagiellowicz, J., Swart, P. J., Abdool, Z., & Dietz, H. P. (2022) · The Obstetrician & Gynaecologist · doi:10.1111/tog.12815 · Cited by 7 · see citing works
Self-citationCrowley, C. M., Lang, N. A., OʼLeary, B. D., & Geary, M. P. (2023) · International Journal of Gynecology & Obstetrics · doi:10.1002/ijgo.14736 · Cited by 7 · see citing works
Re: Assisted vaginal birth: Green‐top Guideline No. 26
de Leeuw, J. W., & Daly, J. O. (2020) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.16508 · Cited by 7 · see citing works
The effect of replacing vacuum with forceps in operative vaginal delivery: an observational study
Caudwell‐Hall, J., Shek, C., Langer, S., & Dietz, H. P. (2020) · International Urogynecology Journal · doi:10.1007/s00192-020-04352-y · Cited by 6 · see citing works
Self-citationZhou, B., Zhang, H., Yuan, J., Bu, C., & Lai, W. (2020) · International Urogynecology Journal · doi:10.1007/s00192-020-04514-y · Cited by 6 · see citing works
Rotstein, E., Ullemar, V., Starck, M., & Tegerstedt, G. (2023) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.14633 · Cited by 6 · see citing works
Cavalcanti, D. B. A., & Lemos, A. (2020) · Journal of Pediatric and Adolescent Gynecology · doi:10.1016/j.jpag.2020.06.011 · Cited by 6 · see citing works
Kimmich, N., Birri, J., Zimmermann, R., & Kreft, M. (2020) · Swiss Medical Weekly · doi:10.4414/smw.2020.20280 · Cited by 4 · see citing works
Chill, H. H., Karavani, G., Lipschuetz, M., Yishai, K., Winer, J. D., Shimonovitz, T., & Shveiky, D. (2022) · International Urogynecology Journal · doi:10.1007/s00192-022-05207-4 · Cited by 4 · see citing works
Is urethral pressure associated with parity and delivery mode?
Shek, K. L., & Dietz, H. P. (2022) · International Urogynecology Journal · doi:10.1007/s00192-022-05233-2 · Cited by 4 · see citing works
Self-citationMaternal birth trauma and its consequences: time to raise awareness
Freeman, R. M., de Leeuw, J. W., & Wilson, P. D. (2021) · International Urogynecology Journal · doi:10.1007/s00192-021-04873-0 · Cited by 4 · see citing works
Impact of the type of vaginal assisted delivery on the pelvic floor and OASI – Ultrasound study
Dvořák, J., Poncova, R., Fučík, T., Dietz, H. P., Mašata, J., Martan, A., & Švabík, K. (2024) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2024.12.023 · Cited by 3 · see citing works
Self-citationLino, S. A., Shek, K. L., Caudwell‐Hall, J., Gillor, M., & Dietz, H. P. (2021) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2021.07.018 · Cited by 3 · see citing works
Self-citationEpisiotomy in vacuum extraction, do we cut the levator ani muscle? A prospective cohort study
Ankarcrona, V., Karlström, S., Sylvan, S., Starck, M., Jönsson, M. E., & Wendel, S. B. (2022) · International Urogynecology Journal · doi:10.1007/s00192-022-05188-4 · Cited by 3 · see citing works
Ely, S., Langer, S., Dietz, H. P., & Shek, K. L. (2024) · Obstetric Anesthesia Digest · doi:10.1097/01.aoa.0001192324.13678.cb · Cited by 2 · see citing works
Self-citationShort statured primigravidae: Options for the obstetric management from a survey of UK obstetricians
Rachaneni, S., Gurol‐Urganci, I., Basu, M., Thakar, R., Sultan, A. H., & Freeman, R. M. (2020) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2020.11.013 · Cited by 2 · see citing works
Forceps Application with Intrapartum Ultrasonography
Sainz‐Bueno, J. A., Borrero, C., & García‐Mejido, J. A. (2021) · Springer eBooks · doi:10.1007/978-3-030-57595-3_32 · Cited by 2 · see citing works
The Patient Is Dying of Drug Poisoning—Let's Increase the Dosage!
Dietz, H. P., Langer, S., Shek, K. L., & Pardey, J. (2025) · Australian and New Zealand Journal of Obstetrics and Gynaecology · doi:10.1111/ajo.13898 · Cited by 2 · see citing works
Self-citationFreitas, G. S. D. O., Anzolch, M. J., Capp, E., Ramos, J. G. L., & Picoloto, A. S. B. (2025) · Journal of obstetrics and gynaecology research · doi:10.1111/jog.70156 · Cited by 1 · see citing works
Grindheim, S., Siafarikas, F., Volløyhaug, I., Kessler, J., & Baghestan, E. (2026) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2026.02.018 · Cited by 1 · see citing works
Diagnosis of Levator Ani Muscle Avulsion in Instrumented Delivery: Meta-analysis
García‐Mejido, J. A., Fernández-Palacín, A., Lao-Peña, C., & Sainz‐Bueno, J. A. (2022) · Clinical and Experimental Obstetrics & Gynecology · doi:10.31083/j.ceog4905118 · Cited by 1 · see citing works
Investigating antenatal pelvic floor training using a vaginal balloon device in Czech women
Fousek, K., Mrkvova, K., Branna, T., & Ozana, M. (2023) · British Journal of Midwifery · doi:10.12968/bjom.2023.31.2.82 · Cited by 2 · see citing works
Yi, J., Tang, Z., Wang, L., Zhang, B., Chen, X., & Liu, X. (2026) · International Journal of Women's Health · doi:10.2147/ijwh.s601021
“29 Similar results were observed in a prospective observational study, demonstrating that differences existed at 6 weeks postpartum between the vaginal and cesarean delivery groups considering the measurement of levator hiatus.”
Klinische Relevanz des Ultraschalls in der Urogynäkologie
Skala, C., Steetskamp, J., & Albrich, S. B. (2019) · Frauenheilkunde up2date · doi:10.1055/a-0828-3982
Cavalcanti, D. B. A., & Lemos, A. (2020) · International Journal of Gynecology & Obstetrics · doi:10.1002/ijgo.13176
Freeman, R. M., de Leeux, J. W., & Wilson, P. D. (2020) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2020.04.044
Instrumental Operative Obstetrics
Kessler, J., & Reitter, A. (2021) · Cambridge University Press eBooks · doi:10.1017/9781108863049.056
Lawrence, W. (2009) · Docs.school Publications
Einfluss von Schwangerschaft und Entbindung auf den mütterlichen Beckenboden
Naumann, G. (2022) · Frauenheilkunde up2date · doi:10.1055/a-1372-8074
Sexual Aspects of Pelvic Floor Disturbances/Disorders
Westerik-Verschuuren, L., Holzik-Mensink, M. L., Wieffer-Platvoet, M., & van der Velde, M. (2023) · Springer eBooks · doi:10.1007/978-3-031-18432-1_16
Scott, S. M., & Heinrich, H. S. (2023) · Elsevier eBooks · doi:10.1016/b978-0-443-13911-6.00005-0
Pelvic floor muscle injuries in women with a history of Caesarean section
Melnikova, L. S., Ostatnikova, M., Pšenková, P., Matušíková, Z., KOLLAROVA, K., Serátor, V., BOROVSKA, L., & Záhumenský, J. (2023) · Bratislavské lekárske listy/Bratislava medical journal · doi:10.4149/bll_2023_111
Montejo, R., Hermansson, J., Nilsson, A., Arkel, E., Keller, L., & Gutke, A. (2023) · Research Square · doi:10.21203/rs.3.rs-3288302/v1
Pelvic Floor Trauma After Childbirth
Guedea, M. A., & Peter, D. H. (2023) · Springer eBooks · doi:10.1007/978-3-030-43840-1_38
Delivery: Complicated Vaginal Deliveries and Surgical Interventions
White, S. E., Shirk, S., & Brost, B. C. (2023) · Springer eBooks · doi:10.1007/978-3-030-43840-1_4
Gutartige Veränderungen des Genitals
Anthuber, C. J., Freydanck, M. K., Baier, F., Engel, J. B., Lermann, J. H., & Renner, S. P. (2023) · Springer eBooks · doi:10.1007/978-3-662-59164-2_12
Volløyhaug, I. (2024) · Springer eBooks · doi:10.1007/978-3-031-43095-4_16
Anorectal Pathophysiology and Investigations
Scott, S. M. (2024) · Springer eBooks · doi:10.1007/978-3-031-43095-4_14
Dietz, H. P. (2025) · Springer eBooks · doi:10.1007/978-3-662-67373-7_36
Self-citationStuart, L. G., Shek, K. L., & Dietz, H. P. (2025) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2025.114088
Self-citationPerineal Pelvic Floor Ultrasound: Applications and Literature Review
Shek, K. L., & Dietz, H. P. (2025) · Springer eBooks · doi:10.1007/978-3-031-92486-6_4
Self-citationDietz, H. P. (2025) · International Urogynecology Journal · doi:10.1007/s00192-025-06334-4
Self-citationSheng, X., Dai, Z., Wang, Q., Hu, X., & Yin, H. L. (2025) · Biomedical Signal Processing and Control · doi:10.1016/j.bspc.2025.109201
The pelvic floor dysfunction: Where obstetrics meets urogynecology
Volløyhaug, I., Teleman, P. M., & Robinson, D. (2026) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.70288
Liu, Y. Y., Huang, W. Y., Zhang, Z., Wang, L., Wu, X., Chen, L., & Xia, Y. (2026) · Frontiers in Medicine · doi:10.3389/fmed.2026.1845766
Cekic, S. G., Unal, C., Topkara, Ş. B., Haskoylu, S., Çelik, E., Turğal, M., & Aydın, S. (2026) · International Urogynecology Journal · doi:10.1007/s00192-026-06861-8
Volløyhaug, I., Belluardo, M., Svenningsen, R., Salvesen, K. Å., Belaska, E., & Nyhus, M. Ø. (2026) · International Urogynecology Journal · doi:10.1007/s00192-026-06872-5
- Authors
- Friedman, T., Eslick, G. D., & Dietz, H. P.
- Affiliations
- The University of Sydney (AU)
- Corresponding author
- Dietz, Hans Peter
- Venue
- International Urogynecology Journal
- Published
- 2019-01-16
- Volume
- 30
- Issue
- 6
- Pages
- 901-907
- ISSN
- 0937-3462 (ISSN-L)
- 1433-3023
- OpenAlex
- W2910602652
- Cited by
- 80
- References
- 45
- Citations by year
- 2026: 6 · 2025: 7 · 2024: 6 · 2023: 16 · 2022: 13 · 2021: 13 · 2020: 14 · 2019: 4
- FWCI
- 1.78
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- www.springer.com/tdm (tdm)
- Locations
- International Urogynecology Journal (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Rheumatology › Pelvic floor disorders treatments
- Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Pregnancy-related medical research
- Keywords
- levator ani muscle avulsion, female pelvic organ prolapse, mode of delivery, forceps delivery, vacuum extraction, instrumental delivery, normal delivery, birth trauma, risk factors
- MeSH terms
- Female, Humans, Pregnancy, Wounds and Injuries, Muscle, Skeletal, Delivery, Obstetric
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
