Fundal pressure in the second stage of labor (Kristeller maneuver) and levator ani avulsion
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LETTER TO THE EDITOR
Fundal pressure in the second stage of labor (Kristeller maneuver) and levator ani avulsion Aly Youssef 1
&
Elena Brunelli 1 & Gianluigi Pilu 1
Received: 7 October 2020 / Accepted: 20 October 2020 # The International Urogynecological Association 2020
Dear Editor, We read with interest the recently published article by Dr. Takmaz and colleagues [1]. Similar to our recently published study [2], the authors found that women undergoing fundal pressure in the second stage of labor (Kristeller maneuver) are at a higher risk of having levator ani muscle damage. I would like to congratulate the authors on their work. The detection and reduction of the Kristeller maneuver remain a challenge [3]. The accumulation of information regarding the maneuver, which is widely practiced in many hospitals worldwide, may lead to the prevention of pelvic floor dysfunction for a huge number of women. However, the authors included in their analysis some injuries with uncertain consequences. Our knowledge so far is that there is a significant association between persistent complete levator ani avulsion and pelvic floor dysfunction, especially pelvic organ prolapse [4]. As the authors acknowledge, their evaluation of women 48 h after delivery may have diagnosed many transient findings. Recent studies have demonstrated
* Aly Youssef [email protected] 1
Department of Obstetrics and Gynecology, Sant’Orsola Malpighi University Hospital, University of Bologna, Via Massarenti, 13, 40138 Bologna, Italy
that some postpartum levator ani avulsions disappear after 6 months postpartum [5]. Second, the authors described in their methodology that they followed the previously standardized multislice technique described by Dietz et al. [4] by displaying the views from 5 mm below the plane of minimal hiatal dimensions to 12.5 mm above at 2.5-mm slice intervals. However, in their figure showing the avulsion the authors did not follow these criteria: none of the slices (shown in attached Fig. 1a) included the plane of minimal hiatal dimensions, which runs from the inferior border of the pubic symphysis to the anterior border of the puborectalis muscle (arrow in Fig. 1b). To avoid reconstructing the wrong slices, as previously described, on the three central images, the authors should see some space between the pubic rami on the first image, which will be closing on the second and absent on the third central image. Furthermore, the authors used a 2-mm rather than a 2.5-mm interslice distance. Not following these recommendations may jeopardize the applicability of their data.
Int Urogynecol J Fig. 1 (a) The reference image from Takmaz’s article assessing levator ani avulsion. In (a) the various slices are 2 mm apart from each other, and none of the slices include the plane of minimal hiatal dimensions shown by the arrow that we added in (b)
Compliance with ethical standards Conflicts of interest None.
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References
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Takmaz T, Aydin S, Gorchiyeva I, Karasu AFG. The usual suspect: cross-sectional study of fun
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