Urogynecology: Original Research
Postpartum Recovery of Levator Hiatus and
Bladder Neck Mobility in Relation
to Pregnancy
Jette Str-Jensen, MD, Franziska Siafarikas, MD, Gunvor Hilde,
Kari B, PT, PhD, and Marie Ellstrm Engh, MD, PhD
OBJECTIVE: To study postpartum changes in pelvic floor
morphology in a cohort of primiparous women.
METHODS: Transperineal ultrasound measurements
taken at five examination points, both prepartum
and postpartum, provided data for comparison. Three
hundred nulliparous pregnant women were examined
at 21 weeks of gestation and 274 (91%) at 37 weeks of
gestation. At 6 weeks postpartum, 285 (95%) women
were examined, 198 (66%) at 6 months, and 178 (59%)
at 12 months using transperineal ultrasonography
at rest, during contraction, and during Valsalva
maneuver. The levator hiatus area, bladder neck
mobility, and rest-to-Valsalva hiatal area difference
were assessed.
RESULTS: Approximately 85% had vaginal and 15% had
cesarean deliveries. Demographic characteristics of the
patients lost to follow-up were similar to the patients not
lost to follow-up. In the vaginal group, a significant
See related editorial on page 529.
From the Department of Obstetrics and Gynecology and HKH, Research Cen-
tre, Akershus University Hospital, Lrenskog, and the University of Oslo, Faculty
Division Akershus University Hospital, and the Department of Sports Medicine,
Norwegian School of Sport Sciences, Oslo, Norway.
Supported by grants from the Norwegian South-Eastern Regional Health
Authority.
Presented in part at the 43rd Annual Scientific Meeting of the International
Continence Society (ICS 2013), August 2630, 2013, Barcelona, Spain.
The authors thank Kristin Gjestland for image analysis and midwife Tone
Breines Simonsen for recruiting participants and administering clinical appoint-
ments and electronic questionnaires.
Corresponding author: Jette Str-Jensen, MD, Akershus University Hospital,
Lrenskog, Norway; e-mail: jett@ahus.no.
Financial Disclosure
The authors did not report any potential conflicts of interest.
2015 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/15
VOL. 125, NO. 3, MARCH 2015
Copyright by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
PT, PhD, J

urat e_ Saltyt e_ Benth, PhD,
decrease in all measurements was seen during the first
6 months postpartum, being most pronounced for the
levator hiatus area during Valsalva maneuver (23.5 cm2;
P,.001). In the cesarean delivery group, no significant
changes between examination points were found post-
partum. Only the vaginal delivery group showed signifi-
cant increases in all measurements when comparing the
status at 12 months postpartum with 21 weeks of gesta-
tion, most pronounced for levator hiatus area during Val-
salva maneuver (3 cm2; P,.001). However, comparing the
two delivery groups at 12 months postpartum, the only
significant difference found was levator hiatus area dur-
ing contraction.
CONCLUSION: The levator ani muscle has the ability to
recover after pregnancy and delivery, although not all
women recover to pregnancy level. Most of the recovery
occurs during the first 6 months postpartum. Significant
pregnancy-induced changes are not shown to persist 1
year postpartum.
(Obstet Gynecol 2015;125:5319)
DOI: 10.1097/AOG.0000000000000645
LEVEL OF EVIDENCE: II
T
he pelvic floor muscles support the pelvic organs
and play an important role in maintaining their
position and function. The pelvic floor, or pelvic dia-
phragm, forms a sheet of muscle that spans the pelvic
cavity with the levator ani muscle being an essential
part.1 It allows for the passage of the urethra, vagina,
and rectum through the levator hiatus. Many women
experience pelvic organ dysfunction at some stage in
their lives2 and vaginal delivery has been established
as one of the most important risk factors associated
with dysfunction later in life.3
However, it is not only events during parturition
that can affect pelvic organ support. An increase in the
size of the levator hiatus area has been shown to occur
in the antepartum period.46 Women who go on to
OBSTETRICS & GYNECOLOGY 531
have caesarean deliveries may also experience loss of 21 weeks of gestation
pelvic floor support, which strengthens the conclusion Ultrasound examinations (N=300)
Participants enrolled (N=300)
that changes that take place during pregnancy might
cause this effect.7 We have previously reported preg- Study exclusions (n=4)
Intrauterine fetal death: 2
nancy data from this cohort of women,4 but there is Premature delivery at less than
a lack of longitudinal imaging studies addressing pos- 32 weeks of gestation: 2
Dropped out (n=6)
sible changes in levator ani morphology after delivery Missing at this examination (n=16)
compared with changes during pregnancy. Delivery before examination: 15
Missing ultrasound volumes: 1
The aim was to study changes in pelvic floor
37 weeks of gestation
morphology after both vaginal and caesarean deliv- Ultrasound examinations (n=274)
eries using three- and four-dimensional ultrasonogra- Participants enrolled (n=290)
phy and compare these changes with prepartum data
in a cohort of primiparous women followed longitu- Study exclusions (n=1)
Intrauterine fetal death: 1
dinally and examined at five set points. Dropped out (n=4)

MATERIALS AND METHODS 6 weeks postpartum

Ultrasound examinations (n=285)
This prospective cohort study was performed at Participants enrolled (n=285)
Akershus University Hospital, Lrenskog, Norway, Study exclusions (n=75)
from January 2010 to October 2012. This study Randomized to pelvic floor
muscle training: 71
presents data from an observational study on pelvic Pregnant: 4
floor changes during and after pregnancy and data Dropped out (n=12)

analyzed in this study are a follow-up to previously 6 months postpartum

presented data on this cohort of women during preg-
nancy.4 Nulliparous pregnant women were invited to
participate when they attended their routine second-
trimester ultrasound examination at 1822 weeks of
gestation. Inclusion criteria were singleton pregnancy,
speaking a Scandinavian language, being older than
18 years of age with no prior pregnancy lasting more
than 16 weeks, and no serious illness. Exclusion cri-
teria were miscarriage, stillbirth, premature delivery
before 32 weeks of gestation, new pregnancy of more
than 6 weeks, or randomization to intervention with
pelvic floor muscle training at 6 weeks postpartum.8
The Regional Ethics Committee (REK Sr-st D
2009/170) and the Norwegian Social Science Data
Service (2799026) approved the study, and all parti-
cipants gave their written informed consent to
participate.
A power calculation was performed using results
from a previous study9 in which a sample size of 47
was required to detect a 5% change in levator hiatus
area at rest with a two-sided a of 0.05 and a power of
80%. We decided to include 300 women at 21 weeks
of gestation to preserve the power, taking into account
the possibility of women dropping out and exclusions
resulting from women participating in a randomized
controlled trial of postpartum pelvic floor muscle
training.8 Demographic data and delivery data were
collected from the womens electronic medical re-
cords and from a questionnaire exploring additional
background data. All women underwent a three- and
four-dimensional transperineal ultrasonography in the
Ultrasound examinations (n=198)
Participants enrolled (n=198)
Study exclusions (n=7)
Pregnant: 7
Dropped out (n=12)
Missing at this examination (n=1)
Missing ultrasound volumes: 1
12 months postpartum
Ultrasound examinations (n=178)
Participants enrolled (n=179)
Fig. 1. Diagram illustrating the number of women exam-
ined at each consultation and the various reasons for non-
participation.
Str-Jensen. Recovery of the Levator Ani Muscle After Delivery.
Obstet Gynecol 2015.
supine lithotomy position after voiding with a 4- to
8-MHz curved array ultrasonography transducer.
Measurements were taken at rest, during pelvic floor
muscle contraction, and during Valsalva maneuver by
two trained examiners. The women were examined at
21 and 37 weeks of gestation and 6 weeks, 6 months,
and 12 months postpartum.
Correct pelvic floor muscle contraction was
taught by a physiotherapist and verified by observa-
tion of inward perineal movement and vaginal palpa-
tion. The Valsalva maneuver was performed for at
least 6 seconds10; care was taken to avoid cocontrac-
tion of the most medial part of the levator ani muscle
during the Valsalva maneuver.
Each maneuver was recorded three times and
stored offline using anonymous code numbers. The
examiners were blinded to the womens clinical data.

532 Str-Jensen et al Recovery of the Levator Ani Muscle After Delivery OBSTETRICS & GYNECOLOGY

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Table 1. Background Variables of the Study Population

Variable Outcome

Background data at inclusion (N5300)

Prepregnancy BMI (kg/m2) 23.963.9
Maternal age (y) 28.664.3
University or higher education 226/300 (75.3)
Married or cohabitant 287/300 (95.7)
Ethnicity Caucasian 288/300 (96.0)
Delivery data (n5287)
Gestational age at delivery (d) 280.8610.4
Birth weight (g) 3,4976510
Vaginal delivery 243/287 (84.7)
Normal 196/287 (68.3)
Instrumental 47/287 (16.4)
Vacuum 43/287 (15)
Forceps 4/287 (1.4)
Cesarean delivery 44/287 (15.3)
Prelabor and 1st stage 39/287 (13.6)
2nd stage 5/287 (1.7)
Examinations
Gestational age at 1st examination (wk) (N5300) 20.961.4
Vaginal delivery 249/294* (84.7)
Cesarean delivery 45/294* (15.3)
Gestational age at 2nd examination (wk) (n5274) 37.060.7
Vaginal delivery 230/271 (84.9)
Caesarian delivery 41/271 (15.1)
Weeks postpartum at 3rd examination (wk) (n5285) 6.261.1
Vaginal delivery 242/285 (85)
Caesarian delivery 43/285 (15)
Weeks postpartum at 4th examination (wk) (n5198) 26.662.5
Vaginal delivery 159/198 (80.3)
Caesarian delivery 39/198 (19.7)
Weeks postpartum at 5th examination (wk) (n5178) 51.663.5
Vaginal delivery 144/179 (80.4)
Caesarian delivery 35/179 (19.6)
BMI, body mass index.
Data are mean6standard deviation or n/N (%).
* Missing delivery data for six women.

Missing delivery data for three women.

Postpartum, the womens lower abdomen and pelvis
was covered by a sheet and they were asked not to
divulge any information regarding their deliveries.
All volumes were analyzed using 4D View 7.0
and 10.0. The levator hiatus area was measured as the
area bordered by the most medial part of the levator
ani muscle, the symphysis pubis, and the inferior
pubic ramus using methodology as previously
described.4 The bladder neck was measured in the
midsagittal plane using a coordinate system as
described by Peschers11 between rest and Valsalva
maneuver. A higher value represents a more mobile
bladder neck.
Major defects of levator ani muscle were assessed
using tomographic ultrasonography imaging on the
axial plane at maximal pelvic floor muscle contraction.
The plane of minimal hiatal dimensions was used as
a reference plane using the definition described by
Dietz.12 Partial defects were defined as abnormal muscle
insertions present in fewer than all three central planes.
Enlarged levator hiatus (also called ballooning)
was defined as a levator hiatus area of more than 25
cm2 during the Valsalva maneuver.13 The ability of
the levator ani muscle to distend was shown in the
absolute difference between measurements of the
levator hiatus area (cm2) at rest and during maximal
Valsalva maneuver14 named rest-to-Valsalva hiatal
area difference.
Volumes were analyzed by four trained inves-
tigators (with intraclass correlation coefficient greater
than 0.80).4 Evaluations of major levator ani muscle
defects were performed by two of the investigators.
Interrater agreement between them was good to
excellent (k greater than 0.63).15

VOL. 125, NO. 3, MARCH 2015 Str-Jensen et al Recovery of the Levator Ani Muscle After Delivery 533

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 Cesarean delivery Cesarean delivery
15 Vaginal delivery 12 Vaginal delivery

14 11

10
cm2

cm2
13
9
12
8
11 7

10 6
21 weeks 37 weeks 6 weeks 6 months 12 months 21 weeks 37 weeks 6 weeks 6 months 12 months
of gestation of gestation postpartum postpartum postpartum of gestation of gestation postpartum postpartum postpartum

A Time B Time

Cesarean delivery Cesarean delivery

23 2.8
Vaginal delivery Vaginal delivery
21 2.5

19 2.2
cm2

cm
17 1.9

15 1.6

13 1.3
21 weeks 37 weeks 6 weeks 6 months 12 months 21 weeks 37 weeks 6 weeks 6 months 12 months
of gestation of gestation postpartum postpartum postpartum of gestation of gestation postpartum postpartum postpartum

Time Time

Fig. 2. Estimated mean levator hiatus area at rest (A), levator hiatus area during contraction (B), levator hiatus area during
Valsalva maneuver (C), and bladder neck mobility (D) at 21 weeks of gestation, 37 weeks of gestation, 6 weeks postpartum,
6 months postpartum, and 12 months postpartum for vaginal and cesarean deliveries with 95% confidence intervals.
Asterisks indicate significant differences between the two delivery groups.
Str-Jensen. Recovery of the Levator Ani Muscle After Delivery. Obstet Gynecol 2015.

The assessors were blinded to the womens
obstetric history and prior examinations. Images
were analyzed in random order to avoid pairwise
analysis, because it was not possible to blind the as-
sessors to the number of weeks of gestation (eg, vis-
ibility of the fetal head on most images taken at 37
weeks of gestation).
SAS 9.3 and SPSS 20 were used for statistical
analysis. Demographic data and ultrasound measure-
ments were reported as means and standard

Table 2. Change in Levator Hiatus Area at Rest, During Maximal Contraction and during Maximal Valsalva
Maneuver, Bladder Neck Mobility, and Rest-to-Valsalva Hiatal Area Difference Between
Examinations
Postpartum
Variable 6 wk to 6 mo P 6 mo to 12 mo P

Vaginal delivery
Levator hiatus area at rest (cm2) 21.360.2 [242, 159] ,.001 0.260.2 [159, 143] .38
Levator hiatus area contraction (cm2) 21.660.1 [242, 159] ,.001 0.0460.1 [159, 143] .77
Levator hiatus area Valsalva (cm2) 23.560.3 [241, 159] ,.001 0.0160.4 [159, 142] .97
Bladder neck mobility (cm) 20.2260.1 [241, 157] .001 20.0760.1 [157, 142] .35
Rest-to-Valsalva hiatal area difference (cm2) 22.260.3 [241, 159] ,.001 20.160.3 [159, 142] .72
Cesarean delivery
Levator hiatus area at rest (cm2) 0.0260.3 [43, 39] .96 0.360.4 [39, 35] .39
Levator hiatus area contraction (cm2) 0.160.3 [43, 38] .77 0.160.3 [38, 35] .69
Levator hiatus area Valsalva (cm2) 0.360.7 [43, 39] .66 0.360.8 [39, 35] .67
Bladder neck mobility (cm) 0.0560.2 [42, 38] .72 0.0660.2 [38, 33] .69
Rest-to-Valsalva hiatal area difference (cm2) 0.360.7 [43, 38] .66 0.160.7 [38, 35] .84
Data are estimated mean difference6standard deviation [n, n] for each of the examinations included in the comparison unless otherwise
specified.
Bold indicates significant P values.

534 Str-Jensen et al Recovery of the Levator Ani Muscle After Delivery OBSTETRICS & GYNECOLOGY

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deviations or frequencies and percentages. Normality
of the data was assessed visually by histogram and
QQ-plot. Independent samples t test and x2 test (or
Fishers exact test) were used to compare continuous
and categorical background variables between the
study group and background population. The McNe-
mar test was applied for a comparison of major leva-
tor ani muscle defects and enlarged hiatus over time.
A linear mixed model, correctly adjusting for within-
patient correlations as a result of repeated measure-
ments, was used to assess the changes in ultrasound
measurements from 21 weeks of gestation until 1 year
postpartum. Random intercepts accounting for
within-patient variability were included in the model.
Dummy variables were created for each of the five
examination points and included in the model as fixed
effects together with the variable defining delivery
mode. To assess the differences in changes within
the two delivery mode groups, the interaction
between dummies for time and delivery mode was
included. Mixed models utilize all available informa-
tion on participants in contrast to an analysis of vari-
ance. The strength of the linear mixed model is the
ability to handle any degree of imbalance in data,
often occurring as a result of participants dropping
out or missing examinations. P,.05 was considered
significant.
RESULTS
Three hundred pregnant nulliparous women were
included at 21 weeks of gestation. Figure 1 shows
a flow diagram illustrating the number of women
examined at each consultation and the various reasons
for nonparticipation. Of the 300 nulliparous pregnant
women examined at 21 weeks of gestation, 274 (91%)
were examined at 37 weeks of gestation. At 6 weeks
postpartum, 285 (95%) women were examined, 198
(66%) at 6 months, and 178 (59%) at 12 months.
Background variables are presented in Table 1.
Some of these data were originally presented in
a cross-sectional study on continence and pelvic
floor status at midpregnancy.16 Our study sample
was comparable to the total population of nullipa-
rous women scheduled to deliver at Akershus Uni-
versity Hospital during the inclusion period
(n52,621) with respect to age and marital and
cohabitation status and delivery mode, but the
women in the study sample had higher educational
status (75.3% compared with 50.8%, P,.001).
We found no significant differences in back-
ground variables between the women who delivered
vaginally and by cesarean delivery. Demographic
characteristics of the patients lost to follow-up
(n5122) were similar to the patients not lost to
follow-up (n5178) with the exception of a slightly
higher number of married and cohabitant women
completing the study.
Figure 2 shows estimated mean levator hiatus area
and bladder neck mobility for the different delivery
groups from 21 weeks of gestation to 12 months post-
partum. Table 2 shows the estimated mean changes in
variables between examinations postpartum as well as
between 12 months postpartum and pregnancy.
A significant change toward a smaller levator
hiatus area at rest, during contraction, and during

12 Mo Postpartum Versus Pregnancy

12 mo Postpartum Versus 21 wk of Gestation P 12 mo Postpartum Versus 37 wk of Gestation P

0.560.2 [143, 249] .002 21.460.2 [143, 230] ,.001

0.760.1 [143, 249] ,.001 20.560.1 [143, 230] ,.001
3.060.4 [142, 249] ,.001 20.260.4 [142, 230] .56
0.5360.1 [142, 248] ,.001 0.4660.1 [142, 230] ,.001
2.560.3 [142, 249] ,.001 1.360.3 [142, 230] .001

20.460.3 [35, 45] .26 22.460.4 [35, 41] ,.001

20.360.3 [35, 45] .29 21.560.3 [35, 41] ,.001
1.160.8 [35, 45] .15 22.460.8 [35, 41] .002
0.2360.2 [33, 45] .13 0.0160.2 [33, 41] .62
1.661.2 [35, 44] .19 0.0660.7 [35, 41] .93

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Table 3. Estimated Mean Differences Between Vaginal and Cesarean Delivery for Levator Hiatus Area at
Rest, During Contraction, and During Valsalva Maneuver, Bladder Neck Mobility, and Rest-to-
Valsalva Hiatal Area Difference During Pregnancy and Postpartum
Pregnancy
Variable 21 wk of Gestation P 37 wk of Gestation P

Levator hiatus area (cm2)

At rest 0.160.4 [249, 45] .80 0.160.4 [230, 41] .81
Contraction 0.460.3 [249, 45] .26 0.460.3 [230, 41] .26
Valsalva 0.160.9 [249, 45] .89 0.260.7 [230, 41] .82
Bladder neck mobility (cm) 0.0460.2 [248, 45] .78 0.160.2 [230, 41] .43
Rest-to-Valsalva hiatal area difference (cm2) 0.0360.8 [249, 44] .97 0.360.6 [230, 41] .67
Data are estimated mean difference6standard deviation [number of vaginal deliveries, number of cesarean deliveries] at each examination
unless otherwise specified.
Bold indicates significant P values.

Valsalva maneuver and further a decrease in bladder
neck mobility was found in the vaginal group from 6
weeks to 6 months postpartum. From 6 months to 12
months postpartum, no further significant change was
found in these variables. For the women who had
a cesarean delivery, no significant change was found
among any of the examination points postpartum.
Comparison between delivery mode groups
showed that women having delivered vaginally had
significantly larger levator hiatus measures and
increased bladder neck mobility both at 6 weeks and
at 6 months postpartum when compared with women
having a caesarean delivery (Table 3). At 12 months
postpartum a significant difference between delivery
mode groups was only found for levator hiatus during
contraction.
At 6 weeks postpartum, major defects of the
levator ani muscle were diagnosed in 26 of 179
(14.5%) women, all of whom had delivered vaginally;
of these, 14 had delivered normally and 12 had an
instrument-assisted delivery. No major defects were
diagnosed in women who had a cesarean delivery. A
significant reduction in diagnosed major levator ani
muscle defects was seen from 6 weeks (26/179 [14.5%])
to 6 months (19/179 [10.6%]) postpartum (P5.016)
with minor changes occurring between 6 and 12
months (16/179 [8.9%]). For the 10 defects no longer
qualifying as major defects at 12 months, six were cat-
egorized as partial defects and four as normal. No de
novo major levator ani muscle defects were diagnosed
at 6 months or 12 months postpartum.
In the vaginal group there was a significant
(P5.025) reduction in the number of women with
enlarged levator hiatus between 6 weeks and 6
months postpartum (Table 4). No further reduction
happened from 6 to 12 months postpartum. For the
caesarean delivery group, the number of women with
enlarged levator hiatus remained stable in the post-
partum period.
The only significant difference between delivery
groups in the number of women with enlarged levator
hiatus was found at 6 weeks postpartum, in which
more women having delivered vaginally had an
enlarged levator hiatus (Table 4).
Measuring the rest-to-Valsalva hiatal area differ-
ence (Fig. 3), a significant reduction was found only in
the vaginal delivery group from 6 weeks to 6 months
postpartum with no further change from 6 to 12
months postpartum (Table 2). In group comparisons,
the vaginal group showed a significantly greater rest-
to-Valsalva hiatal area difference at 6 weeks postpar-
tum than the cesarean delivery group (Fig. 3; Table 3).

Table 4. Percentage and Absolute Numbers of Women With Enlarged Levator Hiatus Area During Valsalva
Maneuver (Levator Hiatus Area Greater Than 25 cm2)

21 wk of 37 wk of 6 wk 6 mo 12 mo
Variable Gestation Gestation Postpartum Postpartum Postpartum

Enlarged levator hiatus

Vaginal delivery (n5142) 4.9 (7) 13.4 (19) 26.8 (38) 14.8 (21) 14.1 (20)
Cesarean delivery (n535) 2.9 (1) 20.0 (7) 11.4 (4) 5.7 (2) 14.3 (5)
Data are % (n).

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 Postpartum
6 wk P 6 mo
2.460.4 [242, 43] ,.001 1.260.4 [159,
3.260.3 [242, 43] ,.001 1.460.3 [159,
6.160.9 [241, 43] ,.001 2.361.0 [159,
0.760.2 [241, 42] ,.001 0.460.2 [157,
3.760.8 [241, 43] ,.001 1.260.8 [159,
However, at 6 months and 12 months postpartum, the
two delivery groups did not differ significantly.
When comparing levator hiatus measurements
and bladder neck mobility at 12 months postpartum
with measurements at 21 weeks of gestation, there
were significant increases in all measurements in the
vaginal delivery group (Fig. 2; Table 2). However, if
comparing measurements at 12 months postpartum
with those of 37 weeks of gestation, there was a signif-
icant decrease in the levator hiatus area at rest and
during contraction, although not during Valsalva
maneuver. In the vaginal delivery group, bladder neck
mobility was significantly higher at 12 months postpar-
tum than at 37 weeks of gestation. For the cesarean
group no significant changes were seen when compar-
ing levator hiatus measurements or bladder neck
mobility at 12 months postpartum with 21 weeks of
gestation. However, when comparing 12 months post-
partum with 37 weeks of gestation, there was a signifi-
cant decrease in all levator hiatus area measurements
for the cesarean delivery group. No significant differ-
ence was seen for bladder neck mobility.
In the vaginal delivery group, the number of women
with enlarged levator hiatus had increased significantly
(P5.02) at 12 months postpartum when compared with
21 weeks of gestation (Table 4) but not when compared
with 37 weeks of gestation. For the cesarean delivery
group, the number of women whose levator hiatus
became enlarged between 21 weeks of gestation and
12 months postpartum (Table 4) was greater than in
the vaginal delivery group. However, this may not be
statistically significant as a result of the small sample size.
Major defects of the levator ani muscle were
diagnosed only postpartum in the vaginal delivery
group, so compared with prepartum figures, there was
a substantial increase 1 year postpartum.
The rest-to-Valsalva hiatal area difference was
significantly increased for the vaginal delivery group
when comparing 12 months postpartum with 21 and
37 weeks of gestation (Table 2; Fig. 3). For the cesarean
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P 12 mo P
39] .006 1.060.4 [143, 35] .02
38] ,.001 1.460.4 [143, 35] ,.001
39] .01 2.061.0 [142, 35] .05
38] .01 0.360.2 [142, 33] .12
38] .14 1.060.8 [142, 35] .25
delivery group, the rest-to-Valsalva hiatal area differ-
ence remained unchanged compared with pregnancy.
DISCUSSION
Our findings indicate that the levator ani muscle has
an ability to recover from the effects of pregnancy and
delivery; however, not all women recover to their
pregnancy level. Most of the recovery happens during
the first 6 months postpartum.
Strengths of the study include the longitudinal
design, high interobserver reliability of data,17 and use
of a linear mixed model, accommodating for imbal-
ance in data and for correlations among repeated
measures. Limitations include the limited number of
cesarean deliveries and unavailability of prepregnant
measurements. We have chosen .05 as the level of
significance. However, to reduce the risk of false-
positive findings resulting from multiple tests, findings
with levels of significance above .01 should be inter-
preted with caution.
Most of the recovery of the levator ani muscle
happens during the first 6 months after delivery.
Magnetic resonance imaging studies report recovery
during the first months postpartum,18,19 whereas
others found no significant changes in levator hiatus
dimensions from 4 months to 3 years postpartum.20
This is in accordance with our findings and could
indicate that recovery takes place early postpartum,
but the duration of recovery varies according to
whether the changes were induced by pregnancy,
delivery, or both, as seen in Figure 2.
We found increased bladder neck mobility after
vaginal delivery with a tendency for recovery the first 6
months postpartum in accordance with several other
studies.2124 Diverging conclusions concerning bladder
neck mobility after cesarean delivery have been pub-
lished.21,24,25 However, most studies are in accordance
with our results showing that bladder neck mobility is
not significantly increased after cesarean delivery.
Recovery of the Levator Ani Muscle After Delivery 537
 10
Cesarean delivery
9
Vaginal delivery
8 Fig. 3. Rest-to-Valsalva estimated
7 mean hiatal area difference at 21
6
weeks of gestation, 37 weeks of
cm2

gestation, 6 weeks postpartum, 6

5 months postpartum, and 12
4 months postpartum for vaginal
and cesarean deliveries in cm2
3
with 95% confidence intervals.
2 Asterisk indicates significant dif-
1 ferences between the two delivery
21 weeks 37 weeks 6 weeks 6 months 12 months groups.
of gestation of gestation postpartum postpartum postpartum Str-Jensen. Recovery of the Levator
Ani Muscle After Delivery. Obstet
Time Gynecol 2015.

The largest change in the prevalence of visible
major levator ani muscle defects was found during the
first 6 months postpartum. Overdiagnosing early after
delivery as a result of edema26 has been put forward as
a possible reason for the decrease in numbers of vis-
ible defects seen later postpartum, but a natural heal-
ing process cannot be excluded.20,27
The rest-to-Valsalva hiatal area difference and the
number of women with an enlarged levator hiatus both
decreased most during the first 6 months after vaginal
delivery. Interestingly, the number of women having an
enlarged levator hiatus increased during pregnancy4 and
at 1 year postpartum, no difference between delivery
groups was found. An increased ability to stretch the
muscle fibers and the connective tissue during pregnancy
might help protect the muscle during parturition,28
although postpartum the same features have been put
forward as an indicator of less firm support for the pelvic
organs.14 Furthermore, it is not known whether an
enlarged levator hiatus 1 year postpartum is associated
with pelvic organ prolapse as it is later in life.29
Even if recovery takes place, the levator ani muscle
does not seem to have recovered completely 12
months after pregnancy and vaginal delivery. Similar
findings have been reported in another longitudinal
study.14 Injury to the muscle, but also injury to the
connective tissue and nerves, might contribute.
Contrary to others,14,21,24 we found no evidence
that changes in levator ani muscle morphology seen
during pregnancy, reflected as changes after cesarean
delivery, persisted 1 year postpartum. In the cesarean
delivery group, we found a small increase in the rest-
to-Valsalva hiatal area difference, an increase of mean
levator hiatus area during Valsalva maneuver of 1
cm2, and also an increase in the number of women
with enlarged levator hiatus at 12 months postpartum
compared with pregnancy. Furthermore, when com-
paring the two delivery groups, no significant differ-
ences were found in bladder neck mobility, enlarged
levator hiatus, and the rest-to-Valsalva hiatal area dif-
ference 1 year postpartum. This could indicate a trend
toward persistent pregnancy-induced changes, as
found in other studies.14,24 However, these findings
did not reach statistical significance in our population
using linear mixed models.
The clinical implications of our findings suggest
that most women can be reassured that recovery takes
place after delivery, although they must be aware that
some changes may persist.
We found that the levator ani muscle has a large
potential for recovery from both pregnancy and
delivery in the majority of women. We found no
evidence that changes in levator ani muscle morpho-
logy seen during pregnancy persisted 1 year post-
partum. However, the fact that the levator ani muscle
has undergone these changes during pregnancy might
make the pelvic floor less able to withstand the
development of pelvic floor disorders when other risk
factors are added later in life.
REFERENCES
1. Ashton-Miller JA, DeLancey JO. Functional anatomy of the
female pelvic floor. Ann N Y Acad Sci 2007;1101:26696.
2. Ashton-Miller JA, Delancey JO. On the biomechanics of vagi-
nal birth and common sequelae. Annu Rev Biomed Eng 2009;
11:16376.
3. Patel DA, Xu X, Thomason AD, Ransom SB, Ivy JS,
DeLancey JO. Childbirth and pelvic floor dysfunction: an epi-
demiologic approach to the assessment of prevention opportu-
nities at delivery. Am J Obstet Gynecol 2006;195:238.
4. Str-Jensen J, Siafarikas F, Hilde G, B K, Engh ME. Ultraso-
nographic evaluation of pelvic organ support during pregnancy.
Obstet Gynecol 2013;122:32936.
5. Dietz HP. Levator function before and after childbirth. Aust N
Z J Obstet Gynaecol 2004;44:1923.

538 Str-Jensen et al Recovery of the Levator Ani Muscle After Delivery OBSTETRICS & GYNECOLOGY

Copyright by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
 6. Chan S, Cheung R, Yiu K, Lee L, Leung T, Chung T. Pelvic
floor biometry during a first singleton pregnancy and the rela-
tionship with symptoms of pelvic floor disorders: a prospective
observational study. BJOG 2014;121:1219.
7. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. Prevalence and
risk factors for pelvic organ prolapse 20 years after childbirth:
a national cohort study in singleton primiparae after vaginal or
caesarean delivery. BJOG 2013;120:15260.
8. Hilde G, Str-Jensen J, Siafarikas F, Ellstrm Engh M, B K.
Postpartum pelvic floor muscle training and urinary incontinence:
a randomized controlled trial. Obstet Gynecol 2013;122:12318.
9. Braekken IH, Majida M, Engh ME, B K. Morphological
changes after pelvic floor muscle training measured by 3-
dimensional ultrasonography: a randomized controlled trial.
Obstet Gynecol 2010;115:31724.
10. Orejuela FJ, Shek KL, Dietz HP. The time factor in the assess-
ment of prolapse and levator ballooning. Int Urogynecol J
2012;23:1758.
11. Peschers U, Schaer G, Anthuber C, Delancey JO, Schuessler B.
Changes in vesical neck mobility following vaginal delivery.
Obstet Gynecol 1996;88:10016.
12. Dietz HP, Bernardo MJ, Kirby A, Shek KL. Minimal criteria for
the diagnosis of avulsion of the puborectalis muscle by tomo-
graphic ultrasound. Int Urogynecol J 2011;22:699704.
13. Dietz HP, Shek C, De Leon J, Steensma AB. Ballooning of the
levator hiatus. Ultrasound Obstet Gynecol 2008;31:67680.
14. van Veelen GA, Schweitzer KJ, van der Vaart CH. Ultrasound
imaging of the pelvic floor: changes in anatomy during and after
first pregnancy. Ultrasound Obstet Gynecol 2014;44:47680.
15. Staer-Jensen J, Siafarikas F, Hilde G, Braekken IH, B K,
Engh ME. Pelvic floor muscle injuries 6 weeks post partuman
intra- and inter-rater study. Neurourol Urodyn 2013;32:9937.
16. Hilde G, Str-Jensen J, Ellstrm Engh M, Brkken IH,
B K. Continence and pelvic floor status in nulliparous
women at midterm pregnancy. Int Urogynecol J 2012;23:
125763.
17. Siafarikas F, Staer-Jensen J, Braekken IH, B K, Engh ME.
Learning process for performing and analyzing 3D/4D trans-
perineal ultrasound imaging and interobserver reliability study.
Ultrasound Obstet Gynecol 2013;41:3127.
18. Yousuf AA, DeLancey JO, Brandon CJ, Miller JM. Pelvic struc-
ture and function at 1 month compared to 7 months by
VOL. 125, NO. 3, MARCH 2015 Str-Jensen et al
Copyright by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
dynamic magnetic resonance after vaginal birth. Am J Obstet
Gynecol 2009;201:514.e17.
19. Tunn R, DeLancey JO, Howard D, Thorp JM, Ashton-Miller JA,
Quint LE. MR imaging of levator ani muscle recovery following
vaginal delivery. Int Urogynecol J Pelvic Floor Dysfunct 1999;
10:3007.
20. Shek KL, Chantarasorn V, Langer S, Dietz HP. Does levator
trauma heal? Ultrasound Obstet Gynecol 2012;40:5705.
21. Shek KL, Kruger J, Dietz HP. The effect of pregnancy on hiatal
dimensions and urethral mobility: an observational study. Int
Urogynecol J 2012;23:15617.
22. Shek KL, Dietz HP, Kirby A. The effect of childbirth on ure-
thral mobility: a prospective observational study. J Urol 2010;
184:62934.
23. Wijma J, Potters AE, de Wolf BT, Tinga DJ, Aarnoudse JG.
Anatomical and functional changes in the lower urinary tract
following spontaneous vaginal delivery. BJOG 2003;110:
65863.
24. Chan SS, Cheung RY, Yiu K, Lee L, Chung TK. Pelvic floor
biometry of Chinese primiparous women one year after deliv-
ery: a prospective observational study. Ultrasound Obstet Gy-
necol 2014;43:46674.
25. Toozs-Hobson P, Balmforth J, Cardozo L, Khullar V,
Athanasiou S. The effect of mode of delivery on pelvic floor
functional anatomy. Int Urogynecol J Pelvic Floor Dysfunct
2008;19:40716.
26. Miller JM, Brandon C, Jacobson JA, Low LK, Zielinski R, Ash-
ton-Miller J, et al. MRI findings in patients considered high risk
for pelvic floor injury studied serially after vaginal childbirth.
AJR Am J Roentgenol 2010;195:78691.
27. Branham V, Thomas J, Jaffe T, Crockett M, South M,
Jamison M, et al. Levator ani abnormality 6 weeks after deliv-
ery persists at 6 months. Am J Obstet Gynecol 2007;197:65.
e16.
28. Siafarikas F, Str-Jensen J, Hilde G, B K, Ellstrm Engh M.
Levator hiatus dimensions in late pregnancy and the process of
labor: a 3- and 4-dimensional transperineal ultrasound study.
Am J Obstet Gynecol 2014;210:484.e17.
29. Dietz HP, Franco AV, Shek KL, Kirby A. Avulsion injury and
levator hiatal ballooning: two independent risk factors for pro-
lapse? An observational study. Acta Obstet Gynecol Scand
2012;91:2114.
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