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Title: Changes to the primiparous pelvis as a result of childbirth
Author: Toozs-Hobson, Philip Milton.
Awarding Body: King's College London (University of London)
Current Institution: King's College London (University of London)
Date of Award: 2003
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Childbirth is associated with considerable change to the mother physically and emotionally. Physically these changes occur as a result of hormonal variations resulting in changes to the biochemical configuration of tissues, pressure effects from the gravid uterus and distortion and disruption during parturition. Until recently assessment of the changes to the pelvic soft tissues has been difficult to investigate. The objective of this thesis was to investigate these changes as a result of childbirth. The hypothesis applied was that childbirth (by whatever mode of delivery) did not cause alteration in the symptoms or ultrasound appearance of the pelvic soft tissues including the urethra. The first part of the thesis relates to validation of the techniques used. Primiparous women were investigated in the third trimester, at six weeks and at six months postnatally with symptom questionnaires, ultrasound scans and neurophysiological assessments. 114 women were recruited with 83 of them completing all visits. 69% had urinary symptoms antenatally. 51% of the women delivered vaginally and 28% of those delivered by caesarean section had symptoms postnatally. The hypothesis was tested by means of systematically analysing the data collected to examine the prevalence of symptoms, and then relate mode of delivery and the presence or absence of symptoms to changes in bladder neck movement, the levator ani complex and the urethral sphincter. Vaginal delivery resulted in bladder neck hypermobility and reduced contractility of the pelvic floor. These changes recovered by 6 months. Caesarean section was associated with a reduction of the levator hiatus, suggesting a pressure effect of the gravid uterus. A comparison of elective with emergency caesarean sections showed a reduction in the ability to distend the pelvic floor in the emergency caesarean group. This difference may give a clue to the reason for Caesarean section and their (reduced) incidence of urinary symptoms. Urinary incontinence and vaginal delivery were accompanied by reductions in the urethral sphincter volume. This appeared to be a separate mechanism for urinary leakage from bladder neck hypermobility. The pressure transmission theory was tested. Loss of pressure transmission occurred with incontinence but was not necessarily present in continent women, suggesting that continence relies on more than bladder neck position alone. From this study it can be concluded that antenatal urinary symptoms are important in the development of postnatal symptoms, and, that vaginal delivery is associated with significant changes to the pelvic floor, which do not occur in women delivered by Caesarean section. This study has also demonstrated that the urethral sphincter is important in maintaining continence. Finally this study suggests that the factors resulting in Caesarean section rather than the Caesarean section itself may be important in whether a woman is at risk of urinary symptoms.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available