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Updated: Nov 12, 2025
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Quantification of Levator Ani Hiatus Enlargement by Magnetic Resonance Imaging in Males and Females with Pelvic Organ Prolapse
Published on: April 17, 2019
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Vaginal birth after Cesarean section and levator ani avulsion: a case-control study.
Summary
Women undergoing vaginal birth after Cesarean (VBAC) have a significantly higher risk of levator ani muscle (LAM) avulsion compared to first-time vaginal births. This increased risk of LAM avulsion persists even after accounting for maternal age and BMI.
Area of Science:
- Obstetrics and Gynecology
- Pelvic Floor Imaging
- Maternal-Fetal Medicine
Background:
- Vaginal birth after Cesarean (VBAC) is an alternative to repeat Cesarean delivery.
- Pelvic floor trauma, including levator ani muscle (LAM) avulsion, is a known complication of vaginal birth.
- The specific risk of LAM avulsion following VBAC compared to vaginal birth in nulliparous women requires further investigation.
Purpose of the Study:
- To compare the incidence of levator ani muscle (LAM) avulsion and levator hiatus enlargement between women undergoing VBAC and primiparous women with vaginal delivery.
- To assess the impact of VBAC on pelvic floor trauma using four-dimensional pelvic floor ultrasound.
Main Methods:
- An observational case-control study was conducted involving women with term VBAC and a control group of primiparous women with vaginal delivery.
- Four-dimensional pelvic floor ultrasound was used to assess LAM avulsion and levator hiatus dimensions at rest and during Valsalva maneuver.
- Statistical analysis, including chi-squared and Wilcoxon tests, and multivariate regression controlling for age and BMI, was performed to compare the groups.
Main Results:
- Women in the VBAC group (n=141) showed a significantly higher rate of LAM avulsion (32.6%) compared to the control group (n=113) (18.6%; P=0.01).
- This increased risk of LAM avulsion in the VBAC group remained significant after adjusting for age and BMI (adjusted odds ratio 2.061).
- No significant differences were found in the area of the levator hiatus or the incidence of levator hiatal ballooning between the two groups.
Conclusions:
- Vaginal birth after Cesarean (VBAC) is associated with a substantially higher risk of levator ani muscle (LAM) avulsion compared to vaginal birth in nulliparous women.
- The findings highlight a specific pelvic floor vulnerability following VBAC, independent of maternal age and BMI.
- These results underscore the importance of considering pelvic floor integrity in the management of VBAC.
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