Pelvic floor muscle dysfunction (PFD) and diastasis recti abdominis (DRA) are very frequent in the immediate postpartum period [1, 2]. Substantiated evidence is imperative to develop prevention strategies targeting the risk factors of these conditions. This study aims to determine the impact of vaginal delivery (VD) on PFD and the prevalence of PFDs in the early postpartum period (6-14 weeks postpartum). Secondary outcome of interest is to questing about a possible connection between DRA and PFDs over the same postpartum period.

Systematic review of contemporary studies (published since 2000). Prospero registration number CRD420251026419.The search of the eligible studies was conducted according to PRISMA guidelines in the relevant international databases (Embase Central, Medline, Cochrane Library) and in the relevant grey literature. Studies where the incidence of urinary incontinence (UI), fecal incontinence (FI), anal incontinence (AI), pelvic organ prolapse (POP) and sexual dysfunction after VD, and DRA after birth, was reported at 6-14 weeks postpartum, were eligible. Only randomized controlled trials and prospective studies were finally included in the review and the assessment of risk of bias was performed by two researchers independently (K.I. and M.T.). Quality assessment was performed using RoB2 and ROBINS-I tools.

The search retrieved 927 articles. Finally, 14 studies (5.303 women) met the inclusion criteria and were analyzed further in this systematic review. Primary outcomes (Table 1): at 6-14 weeks post-partum, the incidence of (1) urinary incontinence is 29.0%-46.6%, (2) stress UI is 8.2%-85.7%, (3) urinary urgency is 0%-89.3%, (4) urge UI is 0-12,7%, (5) AI is 1.8%-45.1%, (6)FI is 0-11.0%, and (7) perineal pain is 7.0%-22.0%. Post-partum at 6-14 weeks, 57.0%-89.5% of the women were sexually active and 32.0%-71.3% had dyspareunia. The presence of DRA ranged from 4.1%-37.9%.POP higher than stage 2 was not reported in any study. No meta-analysis regarding the factors that are associated to each of the PFDs was feasible due to extensive heterogeneity of the studies. OASI was related with increased incidence of every PFD. Multiparity, increased 2nd stage duration, and forceps delivery, were associated with increased incidence of SUI, urinary urgency, AI, and FI.The impact of episiotomy elicited conflicting results.No association was shown between DRA and any PFD.

The incidence of PFDs in the early post-natal period appears to be extremely high. Although most of these symptoms alleviate or disappear over time, the medical personnel should counsel and treat as appropriately each patient when necessary. Urinary incontinence (both SUI & UUI) is very common, dyspareunia, AI & FI are frequent. OASI and forceps delivery appear to be associated with higher rates of PVDs. The role and the type of episiotomy in the development of PFDs is inconclusive. Short and increased duration of 2nd stage are likely to provoke increased rates of PFDs. The significance of DRA as well as the incidence and risk factors for POP in the immediate post-partum period needs further investigation.

The obstetric risk factors that contribute to the occurrence of PFDs are multifactorial and differ in the type of PFDs they cause. OASI and forceps delivery is a common risk factor for AI, FI and UI while OASI is responsible also for sexual dysfunction due to the intense morbidity it causes. More studies of high methodological quality are needed and additionally regression analysis would help to determine the interactions between risk factors.

DeLancey JOL, Kane Low L, M Miller J, A Patel D, A Tumbarello J. Graphic integration of causal factors of pelvic floor disorders: an integrated life span model. American Journal of Obstetrics and Gynecology 2008; 199(6): 610.E1–610.E5. doi:10.1016/j.ajog.2008.04.001
Michalska A, Rokita W, Wolder D, Pogorzelska J, Kaczmarczyk K. Diastasis recti abdominis - a review of treatment methods. Ginekologia Polska 2018; 89(2): 97-101. doi:10.5603/GP.a2018.0016