Fundal pressure in the second stage of labor (Kristeller maneuver) and levator aniavulsion
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AUTHOR RESPONSE (INVITATION)
Fundal pressure in the second stage of labor (Kristeller maneuver) and levator aniavulsion Taha Takmaz 1 & Serdar Aydın 2
&
Ayse Filiz Gökmen Karasu 1
Received: 21 October 2020 / Accepted: 16 November 2020 # The International Urogynecological Association 2020
Dear Editor, We would like to thank Youssef and colleagues for their interest in our study [1]. As they mentioned, similar to their pioneering study we found a higher risk of levator ani muscle (LAM) defect immediately after vaginal delivery [2]. Also, we reported a higher risk of “loss of tenting,” which represents damage to the anterior vaginal wall support. In a longitudinal follow-up study of LAM avulsion continuing for 3–5 years, significant prolapse of the anterior vaginal wall was represented specifically as Aa and Ba points rather than apical and posterior vaginal wall prolapse [3]. We agree with the statement that accumulation of information regarding the deteriorating effect of fundal pressure at the second stage of labor on pelvic floor function will give rise to caution and hopefully abandonment of this detrimental maneuver. In a review of the literature on the natural history of LAM avulsion, van Delft et al. reported that 62% of major LAM avulsions which were diagnosed at 3 months postpartum were no longer evident (healed) at 1-year follow-up [4]. Healing of LAM avulsion, detected 8 weeks after delivery, was reported
* Serdar Aydın [email protected] 1
Department of Obstetric and Gynecology, Bezmialem Vakif University, İstanbul, Turkey
2
Department of Obstetric and Gynecology Koc University School of Medicine Davutpasa Cad No: 4, Topkapi İstanbul Turkey
in 13% of women in another longitudinal follow-up study [3] Additionally, a study by van Delft et al. that evaluated the alteration in early postpartum changes in LAM with highresolution endovaginal ultrasonography showed hematomas at the site of LAM attachment to the pubic bone always resulted in avulsion [5]. In our previous series, which evaluated the changes in LAM immediately after delivery and 3 months postpartum, 48.3% of defects detected immediately after delivery were resolved in 3 months [6]. However, to the best of our knowledge, there is no present information about the functional consequences of these early findings and the causality they might be related to. We know that pelvic floor damage can occur without apparent levator avulsion. Youssef et al. are right about the criticism regarding our figure which represents the avulsion. The location of planes and slice intervals were not represented in the manner we defined in our methodology. To represent demonstrative avulsion an improper image was selected. We are supplying a more correct figure which depicts the correct plane of minimal hiatal dimensions in accordance with the methodology of our study (Fig. 1).
Int Urogynecol J Fig. 1 Slices including the plane of minimal hiatal dimensions with 2.5-mm slice intervals
Author contributions In this Letter to the Editor, Taha Takmaz, Serdar Aydın a
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