| BackgroundFemale pelvic floor dysfunction mainly includes urinary stress incontinence, pelvic organ prolapse, and at the same time associated with the sexual dysfunction, chronic pelvic pain and abnormal defecation or urination. With the aging population and improvement in quality of life, more and more people pay close attention to it. With the gradually increasing incidence, it has become a worldwide social and health issues, seriously effecting the health and quality of life problem of women in the reproductive and menopausal years, bringing a heavy financial burden to society.The etiology of pelvic floor dysfunction is multi-factorial. The pelvic floor support system can affect the function of pelvic floor. Levator ani muscles is the most powerful part of the pelvic support system, which consist of pelvic floor muscles and pelvic connective tissue, plays a major role in support of the pelvic organs. Many studies shown that levator ani muscle injury is closely associated with pelvic floor dysfunction. The studies about that have become a hot spot. With directly damaging levator ani muscle, changing the structure and function of pelvic floor, Pregnancy and delivery has been thought to be one of etiological factors for pelvic floor dysfunction. But there are still controversy on the impact of different delivery mode on the pelvic floor. Some reachers suggested that elective cesarean section can reduce the damage to the pelvic floor. However, some of them believe that there is no discriminatory on impact to the pelvic floor between the elective cesarean section and vaginal delivery.With developing on the medical diagnosis and treatment technology, more and more imaging technology has been applied to evaluate pelvic floor dysfunction. Ultrasound can diagnose pelvic floor dysfunction with non-invasive, inexpensive, easy to operat as well as the application of real-time imaging technology. There have been a lot of overseas researches on ultrasound of female pelvic floor, but there are less domestic related studies about the evaluation of the impact of different delivery mode on the structure and function of levator ani muscle and the dynamic observation on the recovery of levator ani muscle at post-partum using the transperineal ultrasound.Objective1. Study on effct of the morphous of levator hiatus and function of levator ani muscle after delivery by transperineal three-dimensional ultrasound in order to provide experimental data for the etiology and prevention of pelvic floor dysfunction.2. Dynamic observation on the changes of levator hiatus and levator ani muscle function at different periods of postpartum by transperineal three-dimensional ultrasound in order to diagnose pelvic floor dysfunction early and take pelvic floor rehabilitation training in time at postpartum. Material and methodsResearch objects:32 primiparas who give birth in Obstetrics Department of the First Affiliated Hospital of Guangzhou Medical College during August～December 2009, selecting 21 electing caesarean section and 11vaginal delivery randomly according the ratio 2:1, 13 healthy nulliparas with matched age, height, body mass index as control group during the same period. They are all voluntary to take part in this study. Detect Item(1) Transperineal three-dimensional ultrasound examination:at postpartum 6weeks and 12weeks, measure the diameter of the levator hiatus (Levator hiatal dimeter, LHD), anteroposterior diameter of levator hiatus (Levator hiatal anteroposterior diameter, LHAP), transverse diameter of levator hiatus (Levator hiatal lateral diameter, LHLR), circumference of levator hiatus (Levator hiatal circle, LHC) and the distance from the mid-point of urethra to the medial margin of levator ani muscles (Levator urethra gap, LUG) by transperineal three-dimensional ultrasound at three different states (including rest, Valsalva action and levator ani muscle maximum contraction).(2) To detect the strength of levator ani muscle at constraction state by vaginal palpation, evaluate the grade of levator ani muscle strength according to the Oxford modified scoring system (MOS) .(3) The elasticity of levator ani muscle during maximum contraction is calculated byεcont = CcCornets-tC-lrbe st (εcont stands for the elasticity of levator ani muscle during maximum contraction, Ccont and Crest respectively stand for the circle of levator hiatus at the resting state and the maximum of levator ani muscle state). The smaller theεcont is, the higher the elasticity is. Study Design(1) Comparing the transperineal three-dimensional ultrasound index, levator ani muscle strength and elasticity of vaginal delivery group (11 cases), elective cesarean section group (21 cases) and control group (13 cases) at postpartum 12 weeks.(2) Dynamic observing the changes of the transperineal three-dimensional ultrasound index, levator ani muscle strength and elasticity of elective cesarean group and vaginal delivery group at postpartum 6 weeks and 12 weeks. Statistied analysisAnalyse the datas with SPSS 17.0, Measurement datas were described with the mean and standard deviation, Using Univariate analysis of variance for the comparison during the multi groups of Normal distribution, using independent- samples T test for the compare between the two groups, non-parametric test (K-Independent Samples) for non-normal distribution, linear correlation analysis for linear correlation, there was a significant difference as (P <0.05). ResultsThere were no significant differences during the age, height, body mass index among groups.1. The comparison of transperineal three-dimensional ultrasound index of levator hiatus, levator ani muscle strength and elasticity at postpartum 12 weeks.(1) The comparison of elective cesarean section group and vaginal natural delivary group: At rest, Valsalva movements and levator ani muscle contraction state, comparing LHD(5.01±0.61 cm, 5.71±0.86 cm, 4.32±0.57 cm), LHAP(5.11±0.77 cm, 5.58±0.84 cm, 4.45±0.50 cm), LHLR(3.81±0.22 cm, 4.18±0.28 cm, 3.54±0.30 cm), LHC(14.19±1.10 cm, 15.43±1.71 cm, 13.24±1.48 cm), LUG(1.92±0.26 cm,2.05±0.30 cm,1.90±0.26 cm) of levator hiatus in elective cesarean section group with LHD(5.24±0.60 cm, 5.98±0.68 cm, 4.32±0.47 cm) , LHAP(5.38±0.51 cm, 5.67±0.80 cm, 4.56±0.51 cm), LHLR(3.86±0.40 cm, 4.21±0.49 cm, 3.68±0.50 cm), LHC(15.45±1.07 cm, 16.81±2.07 cm, 15.07±1.15 cm), LUG(1.90±0.22 cm, 2.12±0.32 cm, 1.95±0.30 cm) in vaginal natural delivary group, there were no significant differences respectively (P> 0.05); The leavtor muscle strength of elective cesarean section group was grade 3 in 47.6%, (10/21) patients, while the levator muscle strength of vaginal natural delivary group is equal in grade 2( 27.3%) , garade 3 (27.3%) , grade 4 (27 .3%), there was significant differences(P< 0.05);The mean of levator ani muscleεcont in elective cesarean section group and vaginal natural delivary group was -0.06±0.07 VS -0.08±0.07, there were respectively no significant differences(P> 0.05). (2) The comparison of elective cesarean section group and control group: At rest, Valsalva movements and levator ani muscle contraction state, the dimension of LHD, LHAP, LHLR, LHC, LUG of levator hiatus in elective cesarean section group were longer significantly than LHD(4.50±0.61 cm, 4.98±0.84 cm, 3.80±0.67 cm), LHAP(4.60±0.66 cm, 4.98±0.81 cm, 3.99±0.68 cm), LHLR(3.53±0.40 cm, 3.67±0.27 cm, 3.41±0.45 cm), LHC(13.29±1.25 cm, 14.00±1.54 cm, 12.09±1.13 cm), LUG(1.63±0.27 cm, 1.71±0.27 cm, 1.67±0.43 cm)in control group respectively (P <0.05); The levator muscle strength was weaker significantly than that in control group, the levator muscle strength is grade 4 (58.3%,7/13), (P <0.05); The mean of levator ani muscleεcont in elective cesarean section group was significantly higher thanεcont(-0.21±0.06) in the control group(P <0.05). (3) The comparison of vaginal natural delivary group and the control group: At rest, Valsalva movements and levator ani muscle contraction state, the dimension of LHD, LHAP, LHLR, LHC, LUG of levator hiatus in natural vaginal natural delivary group were significantly longer than those in control group respectively (P <0.05); The leavtor muscle strength was significantly weaker than that in control group(P <0.05);The mean of levator ani muscleεcont in vaginal natural delivary group was significantly higher than that in control group(P<0.05).2. The dynamic changes of transperineal three-dimensional ultrasound index of leavator hiatus, levator ani muscle strength and elasticity in elective cesarean group and natural vaginal delivery group2.1 The comparison of transperinal three-dimensional ultrasound index, levator ani muscle strength and elasticity of vaginal delivery group at postpartum 6 weeks and 12 weeks: At rest, Valsalva movements and levator ani muscle contraction state, the dimension of LHD(5.90±0.86 cm,6.71±0.82 cm,5.07±0.60 cm),LHAP(5.85±0.49 cm,6.46±0.60 cm,5.33±0.55 cm),LHLR(4.45±0.60 cm,4.82±0.53 cm,4.12±0.37 cm),LHC(17.30±1.07 cm,18.30±1.03 cm,16.14±0.94 cm),LUG(2.19±0.30 cm,2.43±0.34 cm,2.31±0.43 cm) of levator hiatus in vaginal natural delivary group at postpartum 6 weeks were respectively longer than those at postpartum 12 weeks, there were significant differences respectively (P <0.05); The leavtor muscle strength at postpartum 6 weeks was grade 1 in 45.5% (5/11) patients, that was significantly weaker than at postpartum 12 weeks, (P <0.05);The mean of levator ani muscleεcont(-0.21±0.06) at postpartum 6 weeks was significantly higher than at postpartum 12 weeks(P <0.05).2.2 The comparison of transperineal three-dimensional ultrasound index of levator hiatus, levator ani muscle strength and elasticity of elective cesarean section group at postpartum 6 weeks and 12 weeks: there were no significant differences between two groups'LHD, LHAP, LHLR, LHC, LUG respectively at rest, Valsalva movements and levator ani muscle contraction state respectively (P >0.05), the levator hiatal LHD(5.32±0.66 cm,6.11±0.71 cm,4.61±0.54 cm),LHAP (5.29±0.61 cm,5.86±0.72 cm,4.76±0.80 cm),LHLR(3.86±0.38 cm,4.06±0.41 cm, 3.51±0.32 cm),LHC(14.14±1.10 cm,15.43±1.71 cm,13.24±1.48 cm),LUG (1.87±0.25 cm,2.01±0.36 cm,1.93±0.28 cm) in election cesarean section group at postpartum 6weeks; The leavtor muscle strength was significantly weaker at postpartum 6 weeks than at postpartum 12 weeks, there was significant difference(P <0.05). The leavtor muscle strength of elective cesarean section group was grade 2 in 61.9% (13/21) patients at postpartum 6weeks. The mean of levator ani muscleεcont(-0.06±0.05) in elective cesarean section group at postpartum 6weeks was no significantly difference comparing to that at postpartum 12weeks (P >0.05). Correlation analysis of levator ani muscle strength and elasticity: at postpartum 6weeks there was significantly correlated withεcont and strength grade , (P <0.05).But at postpartum 12weeks this correlation was no significant, (P >0.05),Conclusion1. The impact of selective cesarean section and natural vaginal delivery on levator hiatual morphous is identical. The changes on levator hiatual morphous caused by selective cesarean section is due to pregnacey.2 .Selective cesarean section effected levator ani muscle less than natural vaginal delivery.The changes on levator ani mucles strength caused by selective cesarean section is due to the injury of levator ani mucles nerves.3. The trend of changes of levator hiatal morplous, levator muscle strength and elasticity is to natrual recovery at postpartum. The recovery of levator hiatal morplous has been completed at 6 weeks postpartum,but cantnot restored to pre-pregnancy condition. Levator ani muscle Injury continued in existence at 12 weeks postpartum due to the nerve injury that hasn't been resumed.4. The changes of levator hiatal morplous, levator muscle strength and elasticity in natural vaginal delivery has not returned to pre-pregnancy condition. So that the recovery exercises can prevent pelvic floor pelvic floor dysfunction...
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