Objective: To identify factors associated with the preferred mode of delivery among women with a prior vaginal birth after caesarean section (VBAC). Design: Secondary analysis of a multicentre observational cohort. Setting: Two tertiary care centres in the Czech Republic Population: Women who had a term VBAC as their second delivery Methods: Participants completed validated questionnaires PFDI-20, PISQ-IR, and ICIQ-SF and underwent 4D transperineal ultrasound to assess levator ani muscle avulsion. Preferred mode of delivery under full autonomy was recorded. Statistical tests were used to identify independent predictors of a preference for caesarean birth. Main Outcome Measures: Self-reported preferred mode of delivery (vaginal vs caesarean). Results: Of 164 women, 64.2% preferred vaginal delivery, 13.9% preferred caesarean, and 21.8% were undecided. On multivariable analysis, obstetric anal sphincter injury (OASI) (OR 8.38, 95% CI 1.20-58.30; p=.031) and episiotomy (OR 3.07, 95% CI 0.98-9.59; p=.047) were associated with a preference for caesarean delivery. Postpartum sexual inactivity was associated with caesarean preference in univariable analyses but was not an independent predictor after adjustment. Conclusions: Most women with prior VBAC preferred future vaginal birth; however, previous perineal trauma, particularly OASI and episiotomy, was associated with a preference for caesarean delivery. These findings support trauma-informed counselling that addresses pelvic floor outcomes and sexual health in shared decision-making.

Objective: Data concerning effect on early postoperative pain and patient satisfaction after laparoscopic sacrocolpopexy (LSC) is lacking. Design: Double-blind randomized controlled trial Setting: Tertiary urogynaecology care centre, Faculty of Medicine in Pilsen, Charles University Population: Women undergoing LSC for stage > 2 pelvic organ prolapse were included. The exclusion criteria were concomitant vaginal surgery including suburethral sling or where vagina was opened during the surgery (including hysterectomy). Women with lost or incompletely filled-in McGill pain questionnaire were additionally excluded from the postoperative pain and satisfaction analysis. Methods: Women were randomized to vaginal packing after LSC with a sterile gauze. The subjective perceptions of pain were measured using McGIll Pain Questionnaire on day one before pack extraction and satisfaction was assessed using VAS on postoperative day 1 and 4. Main outcome measures: Postoperative pain on day after the surgery, patient satisfaction with the surgery and postoperative course on day one and four. Results: In total, 274 women were included in analysis, vaginal pack was inserted in 132 (48%) women. The groups did not differ in basic preoperative nor surgical characteristics. Very low and comparable values of all scores of the McGill Pain Questionnaire were observed (VAS pain 3.2 ±1.8 vs. 3.4±1.9, p=0.330). No difference in patient satisfaction on day one (7.3±1.8 vs. 7.4±1.7, p=0.633) nor overall satisfaction on day 5 (8.7±1.3 vs. 8.8±1.1,p=0.719) was observed. Conclusion: Laparoscopic sacrocolpopexy is associated with low levels of pain and high patient satisfaction regardless of vaginal pack insertion. Vaginal packing does not harm the patients. Clinical trial registration: https://clinicaltrials.gov/study/NCT02943525

Delivering in or out of water, the OASI rates in the POOL cohort study are disturbingly highDear Dr Papageorghiou,We have read with interest the POOL study report by Sanders et al. published in your journal.1 We acknowledge that the results of this study are based on a large obstetric cohort of low-risk women.The mere conclusion of the authors is that birth in water is not associated with increased risks for mothers and babies. However, in doing so, they seem to have overlooked an important issue related to the event rate in their comparator group. Indeed, the reported obstetric anal sphincter injury (OASI) rates of 5.0% in nulliparous and 1.3% in multiparous women are remarkably, if not unacceptably high. Particularly, given the risk for serious, often untreatable complications strongly associated with such injury.The reported event rates in the pool study are an outlier when compared to the 1.6% reported in other studies.3 The reported rates in the POOL study are comparable to those reported by Gurol-Urganci et al.4 Nonetheless, 20% of the women in the Gurol-Urganci et al study had operative vaginal births, a strong risk factor for OASI. In contrast, the POOL study cohort were all low-risk spontaneous births.The POOL study describes women delivering in and out of water, but the authors do not comment if manual perineal protection was used or not in either of the groups. Applying interventions, like manual perineal protection at the time of water birth may be challenging and does not tend to be attempted in some healthcare settings.Manual perineal protection was earlier associated with a significant reduction in OASI risk in Norway and Denmark and the UK. Fodstad et al. describe that the OASI prevalence in Norway in all vaginal deliveries has reduced from 4.2% in 2004 to 1.6% in 2023, after introduction of a national program with manual perineal protection.3Gurol-Urganci et al. have also demonstrated a significant reduction OASI rates in a healthcare setting comparable to that of Saunders et al. Moreover, the RCOG and, more recently, the published report from the All-Party Parliamentary Group on Birth Trauma have recommended the roll out and implementation, underpinned by sufficient training, of the OASI care bundle to all hospital trusts to reduce risk of perineal injuries in childbirth.4 Hence, it would have been expected that a UK based study using perineal trauma as its primary outcome would address and discuss what interventions were undertaken to mitigate the risk of trauma.We believe that there is a high risk that the exceptionally high OASI rate in the comparator arm has introduced bias in this non-inferiority RCT. Sanders et al conclude that their “Study findings provide reassurance that birth in water, in the context of UK midwifery practice, is not associated with increased risks for mothers or their babies. However, given the 2015 Supreme Court Montgomery ruling stating that “clinicians should disclose risks of childbirth” one should question, why the risk of childbirth in the POOL study was so unacceptably high and still remained undiscussed?Jan Willem de Leeuw, Department of Obstetrics and Gynaecology, Ikazia Ziekenhuis Rotterdam, the NetherlandsKatariina Laine, Norwegian Research Centre for Women’s Health, Oslo University Hospital, Oslo, Norway, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, NorwayMargareta Manresa, Clinic Institute of Gynaecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, SpainSari Raisanen, Laurea University of Applied Sciences, Vantaa, FinlandVladimir Kalis, Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Center for Pelvic-floor Disorders, Pilsen, CzechiaZdenĕk Rušavý, Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles UniversityRenaud de Tayrac, Obstetrics and Gynaecology Department, Nimes University Hospital, University of Montpellier, Nimes, France

Objective: To compare patients undergoing laparoscopic sacrocolpopexy for pelvic organ prolapse POP, in terms of sexual function and surgical anatomical outcomes more than 5-years follow up period. Design: This is a cohort study of prospectively collected data that includes all women who underwent LSC between July 2005 and December 2021 at a tertiary care center. Setting: Improvement in sexual function is an acknowledged goal for women undergoing pelvic organ prolapse repair. The impact of POP surgeries on sexual activity and function is very controversial, with some studies showing improvement, while others showed no differences or worsening in sexuality after the surgery Population: 228 women were enrolled in this study. Methods: Patients completed the validated quality of life questionnaires and were evaluated using the POP-Q, the PFDI-20, PFIQ-7 and the PISQ-12 scores. Patients were divided preoperatively according to their sexual activity and postoperatively according to the sexual improvement after POP surgery. Main Outcomes: To compare the PISQ-12 score pre and postoperatively and to assess anatomical and sexual improvement after surgery. Results: There was a statistically significant improvement in the PFDI, PFIQ and POPQ-score score. There was no significant improvement in the PISQ-12 score with more than 5 years follow-up. 76.1% of patients who were not sexually active preoperatively resumed their sexual activity after the surgery. Conclusions: The anatomical correction of a pelvic organ prolapses and pelvic floor disorders by laparoscopic sacrocolpopexy may improve sexual function but did not change significantly the sexuality score. Funding: No funding. Keywords: prolapse, sacrocolpopexy, laparoscopy, sexuality.

Background: There is variation in the reported incidence of levator avulsion (LA). Objective: Explore incidence of LA by mode of birth, imaging modality, timing of diagnosis and laterality of avulsion. Search strategy: We searched MEDLINE, EMBASE, CINAHL, AMED and MIDIRS with no language restriction from inception to April 2019. Study eligibility criteria: A study was included if LA was assessed by an imaging modality after the first vaginal birth or if only delivered by caesarean section. Case series and reports were not included. Data collection and analysis: RevMan v5.3 was used for the meta-analyses and SW SAS and STATISTICA packages for type and timing of imaging analyses. . Results: We included 37 primary non-randomized studies from 17 countries and involving 5594 women. Incidence of LA was 1%, 15%, 21%, 38.5% and 52% following caesarean, spontaneous, vacuum, spatula and forceps births respectively, with no differences by imaging modality. OR of LA following spontaneous birth vs. caesarean was 10.69. While the OR for LA following vacuum and forceps compared to the spontaneous birth were 1.66 and 6.32 respectively. LA was more likely to occur on the right side following spontaneous birth (p = 0.02) and unilaterally vs. bilaterally following spontaneous (P < .0001) and vacuum-assisted births (P = 0.0103) only. Incidence was higher if assessment was performed in the first 4 weeks postpartum. Conclusions: Forceps significantly increases incidence and severity of LA. Ultrasound and MRI are comparable diagnostic tools but early postpartum imaging may lead to over diagnosis of LA.