Clinical Trial of Pushing Timing on Postpartum Pelvic Floor Morbidity at 3 Years

Wednesday, October 23, 2024

3:15 PM – 3:25 PM EDT

Location: Liberty Ballroom (Meeting Level 4)

Flow Diagram of Study Participation

Pelvic Floor Symptom and Quality of Life Questionnaire Scores at Baseline and 2-3 Years

AUGS 2024 Table 1.docx

Objectives: To compare the long-term pelvic floor morbidity in patients randomized to immediate or delayed pushing in the second-stage of labor.

Methods: This study was a multicenter randomized controlled trial that included nulliparous patients at 37 weeks of gestation or greater in labor with neuraxial analgesia. Participants were randomized in the second stage of labor to immediate pushing or delayed pushing 60 minutes after reaching the second stage. Baseline pelvic floor assessments were performed 1–5 days and 2-3 years postpartum. Rates and class of perineal laceration, pelvic organ prolapse quantification (POP-Q) measures, and scores on validated symptom-specific distress and impact on quality-of-life questionnaires (PFDI-20 [Pelvic Floor Distress Inventory], PFIQ [Pelvic Floor Impact Questionnaire], FISI [Fecal Incontinence Severity Index], and MMHQ [Modified Manchester Health Questionnaire]) were compared within and between groups. Subscale questionnaire scores including the Urogenital Distress Inventory (UDI), Pelvic Organ Prolapse Distress Inventory (POPDI), Colorectal Anal Distress Inventory (CRADI), Urogenital Impact Questionnaire (UIQ), Pelvic Organ Prolapse Impact Questionnaire (POPIQ), Colorectal Anal Impact Questionnaire (CRAIQ) were also compared within and between groups. Change in questionnaire scores were adjusted for birthweight >4000g and duration of pushing.

Results: 2,414 participants were randomized between 2014 and 2017. 356 women (14.7%) completed pelvic floor assessments at 2-3 years, 175 in the immediate pushing group and 181 in the delayed pushing group. Patients with an interval pregnancy were excluded (n = 236). Mean age at follow-up was 28.64 ±5.89 years, median time to follow-up was 31 (26,37) months, and 85.1% delivered vaginally. There were no significant differences in age, race, mode of delivery, or class of perineal lacerations at delivery. There was a significant difference in birth weight between immediate vs delayed pushing groups (3273.4 ±459.8 vs 3176.7 ±434.3, respectively, P=0.04). There was also no difference in POP-Q stage at 2-3 years postpartum. Inter- and intra-group changes in total and subscale scores for the PFIQ, FISI, and MMHQ were not significantly different at 2-3 years postpartum, (-12.77 ±47.22 vs -21.99 ±58.74, P=0.09), (-1.17 ±8.04 vs -0.56 ±7.65, P=0.56), and (3.08 ±22.49 vs -0.05 ±20.17, P=0.53), respectively. The changes in PFDI-20 score were not significantly different (3.42 ±29.13 vs 0.38 ±36.23, P=0.40), however, the CRADI score change was significantly different (2.36 ±15.96 vs -5.74 ±15.69, P=0.01), this change being greater than the minimum important difference (MID) of 5.

Conclusions: Among nulliparous patients in the second stage of labor with neuraxial analgesia, immediate pushing, compared with delayed pushing, did not result in clinically significant differences in POP-Q measures and the majority of pelvic floor symptoms at 2-3 years. Delayed pushing resulted in a statistically and clinically meaningful decrease in bowel symptom bother as measured by the CRADI subscale score at 2-3 years.

Disclosure(s):

Collin M. McKenzie, MD: No financial relationships to disclose

Candice L. Woolfolk, PhD, MPH: No financial relationships to disclose

W. Thomas Gregory, MD: No financial relationships to disclose

Amanda B. White, MD: No relevant disclosure to display

Methodius R. Tuuli, MD, MPH, MBA: No financial relationships to disclose

Alan Tita, MD, PhD: No relevant disclosure to display

Sindhu K. Srinivas, MD, MSCE: No financial relationships to disclose

Aaron B. Caughey, MD, MPH, PhD: No financial relationships to disclose

Lily A. Arya, MD: No relevant disclosure to display

Jerry L. Lowder, MD, MSc: No financial relationships to disclose

George Macones, MD: No financial relationships to disclose

Alison Cahill, MD: No financial relationships to disclose

Holly E. Richter, PhD, MD: No relevant disclosure to display

Presenting Author(s)

Collin M. McKenzie, MD

Fellow
Department of Women's Health, Dell School of Medicine, University of Texas at Austin
Pflugerville, Texas, United States

Disclosure(s): No financial relationships to disclose

Co-Author(s)

CW

Candice L. Woolfolk, PhD, MPH (she/her/hers)

Assistant Professor
Washington University School of Medicine Department of Obstetrics & Gynecology
St Louis, Missouri, United States

Disclosure(s): No financial relationships to disclose
W. Thomas Gregory, MD (he/him/his)

Professor
OHSU
Portland, Oregon, United States

Disclosure(s): No financial relationships to disclose
Amanda B. White, MD

Division Chief and Fellowship Director, Urogynecology and Reconstructive Pelvic Surgery
University of Texas at Austin, Dell Medical School
Austin, Texas, United States

Disclosure(s): No relevant disclosure to display
MT

Methodius R. Tuuli, MD, MPH, MBA

Professor and Chair
Warren Alpert Medical School at Brown University
Providence, Rhode Island, United States

Disclosure(s): No financial relationships to disclose
AT

Alan Tita, MD, PhD

Professor
UAB
Birmingham, AL, Alabama, United States

Disclosure(s): No relevant disclosure to display
SS

Sindhu K. Srinivas, MD, MSCE

Professor
Penn Medicine Perelman School of Medicine
Philadelphia, Pennsylvania, United States

Disclosure(s): No financial relationships to disclose
AC

Aaron B. Caughey, MD, MPH, PhD (he/him/his)

Professor and Chair
Oregon Health & Science University
Portland, Oregon, United States

Disclosure(s): No financial relationships to disclose
LA

Lily A. Arya, MD

Professor and Chief
University of Pennsylvania
Philadelphia, Pennsylvania, United States

Disclosure(s): No relevant disclosure to display
Jerry L. Lowder, MD, MSc (he/him/his)

Professor
Washington University in St Louis School of Medicine
St Louis, Missouri, United States

Disclosure(s): No financial relationships to disclose
GM

George Macones, MD

Executive Vice Dean
Dell Medical School
Austin, Texas, United States

Disclosure(s): No financial relationships to disclose
AC

Alison Cahill, MD

Professor, Department of Women's Health
University of Texas at Austin, Dell Medical School
Austin, Texas, United States

Disclosure(s): No financial relationships to disclose
Holly E. Richter, PhD, MD

Professor
University of Alabama at Birmingham
Birmingham, Alabama, United States

Disclosure(s): No relevant disclosure to display