The impact of childbirth on pelvic floor morphology in primiparous
Black South African women: a prospective longitudinal observational
Barend G. Lindeque
Hans P. Dietz
Received: 27 September 2017 /Accepted: 28 November 2017 / Published online: 18 December 2017
The International Urogynecological Association 2017
Introduction and hypothesis There is a lack of prospective studies evaluating the impact of childbirth on the pelvic floor in non-
white populations. We intended to study delivery-related changes in pelvic floor morphology in Black South African primiparae.
We also intended to determine the impact of anatomical changes on symptoms in the postpartum period.
Methods A total of 153 nulliparous women between 35 and 39 weeks gestation were recruited from a district antenatal clinic. All
women had a standardized interview, completed the International Consultation on Incontinence Vaginal Symptoms questionnaire
followed by three/four dimensional transperineal ultrasonography. This was repeated at 3–6 months postpartum.
Results Of the 153 women, 84 (54.9%) returned at a mean of 4.8 months postpartum. Of these women, 60 (71.4%) had a vaginal
delivery and the remainder a caesarean section (20 emergency and 4 elective). Overall, there were statistically significant
increases in bladder neck descent (P = 0.003), pelvic organ descent and levator hiatal distensibility (all P < 0001) at the postpar-
tum assessment. Levator avulsion was diagnosed in nine (15%) of those delivered vaginally. Postpartum vaginal laxity was the
commonest bothersome vaginal symptom, reported by 51 women (60.7%).
Conclusions There is significant alteration in pelvic organ support and levator hiatal distensibility postpartum, with more marked
effects in women after vaginal delivery. Of Black primiparous women, 15% sustained levator trauma after their first vaginal
Pelvic floor morphology
Pelvic floor ultrasonography
An intact levator ani (LA) muscle complex is key to maintain-
ing normal pelvic organ support [1, 2]. Although gross trauma
to this muscle in the form of avulsion injury was described
several decades ago, it is only recently that biomechanical
derangements in the form of altered pelvic organ mobility,
levator hiatal distensibility and levator avulsion have been
described and studied [3–6].
Using three/four dimensional transperineal ultrasonogra-
phy (TPUS) levator avulsion has been shown to occur in
10–30% of women after delivery, and most studies have in-
cluded women of Caucasian and Chinese ethnicity [4, 7–10].
It has recently been shown that, compared to Caucasians and
Asians, Black Ugandan and Black South African nulliparous
women have greater pelvic organ mobility and levator hiatal
distensibility and therefore might be less susceptible to
delivery-related trauma [11, 12]. Cheung et al. reported that
primiparous East Asian women have thicker pubovisceral
muscles, smaller levator hiatal area and less pelvic organ mo-
bility than Caucasian women, supporting the evidence that
interethnic variation is common . It has been claimed that
functional pelvic floor anatomy in Black South African women
differs from that in Caucasian and Asian women [14, 15].
* Zeelha Abdool
Division of Urogynaecology, Department of Obstetrics and
Gynaecology, University of Pretoria, Steve Biko Academic Hospital,
Level 7, Pretoria, South Africa
Department of Obstetrics and Gynaecology, University of Sydney
Medical School Nepean, Kingswood, Australia
International Urogynecology Journal (2018) 29:369–375