Delivery Mode and Pelvic Floor Disfunction

Pelvic floor disorders compromise the quality of life for a lot of women of all ages throughout the world [1]. The prevalence of urinary incontinence (UI) is thought to range from 17 to 45% among adult women. Likewise 50% of parous women have pelvic organ prolapsed [2]. The etiology is thought to be multifactorial [3]. The traditional predisposing factors are thought to be advancing age, childbearing, obesity and menopause [4]. Pregnancy and delivery seem to be major risk factors among young and middle-aged women [5,6]. On reviewing the available evidence, it appears that vaginal delivery may cause damage to the pudendal nerve, the inferior aspects of the levator ani muscle and fascial pelvic organ supports. Traumatic damage to fascial and muscular support structures during childbirth may be, an important contributor to the development of UI and prolapse of pelvic organ (POP) [7]. The prevalence of stress urinary incontinence (SUI) and POP is greater in parous than nulliparous women [8,9] and increases during the pregnancy [10]. A series of risk factors involves both delivery mode and postpartum [11,12]. The aim of this study is to consider the association between operative vaginal birth and pelvic floor disorders (POP and SUI) (Figure 1).


Introduction
Pelvic floor disorders compromise the quality of life for a lot of women of all ages throughout the world [1]. The prevalence of urinary incontinence (UI) is thought to range from 17 to 45% among adult women. Likewise 50% of parous women have pelvic organ prolapsed [2]. The etiology is thought to be multifactorial [3]. The traditional predisposing factors are thought to be advancing age, childbearing, obesity and menopause [4]. Pregnancy and delivery seem to be major risk factors among young and middle-aged women [5,6]. On reviewing the available evidence, it appears that vaginal delivery may cause damage to the pudendal nerve, the inferior aspects of the levator ani muscle and fascial pelvic organ supports. Traumatic damage to fascial and muscular support structures during childbirth may be, an important contributor to the development of UI and prolapse of pelvic organ (POP) [7]. The prevalence of stress urinary incontinence (SUI) and POP is greater in parous than nulliparous women [8,9] and increases during the pregnancy [10]. A series of risk factors involves both delivery mode and postpartum [11,12]. The aim of this study is to consider the association between operative vaginal birth and pelvic floor disorders (POP and SUI) (Figure 1).

Materials and Methods
Data sources: A review of the literature was undertaken using the Medline and Popline CD Rom considering articles published from 1996 to 2011; additional sources were identified from references cited in relevant research articles.
Methods of study selection: we studied articles concerning stress urinary incontinence, pregnancy, childbirth, pelvic prolapse.
Data on any incontinence, in addition to type, frequency, and amount of incontinence is reported.
Solans [13] [19], in 1998 studying the effects of delivery on bladder and anorectal functions, found out a major risk following forceps vaginal operative delivery. 149 nulliparas were evaluated during pregnancy and 9 weeks after delivery. SUI was discovered in 31% patients during pregnancy and in 10% during the postpartum. Women suffered from urinary and fecal incontinence in a percentage of 36% and 4% after forceps and 21% and 5.5% after spontaneous birth, respectively. Bladder neck mobility was increased after vaginal births and more after forceps. In accordance to Meyer, Detz and Bennett [19,20] evaluated the effect of child birth on pelvic organ mobility on a total of 200 women. Peripartal changes in the mobility of urethra, bladder, cervix, and rectal ampulla were correlated with labor and delivery data. The most significant increase in pelvic organ mobility were found after forceps vaginal operative delivery. They concluded that vaginal births has a negative effect on the statics of pelvic floor; the damage involves the whole vaginal compartments. Handa [21]  • the second one: either one or more caesarian sections; • the third category: patients with history of both caesarian section and vaginal delivery.
Women were categorized into one of three groups based on selfreported pregnancy and delivery experience.
On comparing the perception of agreement and disagreement about specific modality of delivery between the first group (vaginal delivery and caesarian section 5 years before), a not significant difference was found (vaginal delivery 92.9%, caesarian section 90.1%, p=0.12645), other that a significant difference among the second group (vaginal delivery 84.9%, caesarian section 89%, p=0.00439), and in the third group found too (vaginal delivery 77%, caesarian section 92%, p=0.0001). The results of this investigation showed the disorder of pelvic floor depends on the main modality of delivery. Anatomic and functional alterations influence both the choice of the patients and either positive or negative perception about birth experience. Agreement or disagreement are interaction with a series of disturbs following the traumatic consequences of the birth, either early or late on pelvic floor. A woman who delivers an infant vaginally has a risk of a pelvic floor disorder that is significant higher than a woman who delivers all infants by caesarean delivery. Development of pelvic floor disorders may be dependent on multiple risk factors, where the most important factor is the modality of delivery. The most usual reasons of disagreement with vaginal delivery were genital prolapse (30%), genital prolapse associated with UI end or anal incontinence (38%), sexual dysfunctions following vaginal birth (29%) and other pelvic disturbances appearing with time [22]. The correlation between delivery mode and pelvic floor alteration were found, in order of severity as following:

Conclusion
Literature research confirms that anatomic and functional damages are linked with obstetric factors. Pregnancy may cause urinary incontinence and genital prolapse. However, Caesarean delivery is associated with a significant lower risk of urinary incontinence and pelvic defects. Caesarean section may protect from perineal risk of delivery but not from the damage due to the pregnancy itself. Forceps is found out the most dangerous instrument for pelvic floor, followed by vacuum and vaginal delivery with tears. The consequences of a