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Maternal adaptations in preparation for parturition predict

uncomplicated spontaneous delivery outcome
Sallie S. Oliphant, MD, MSc; Ingrid E. Nygaard, MD, MSc; Wenjun Zong, MD, PhD; Timothy P. Canavan, MD, MSc;
Pamela A. Moalli, MD, PhD
OBJECTIVE: The objective of the study was to define maternal tissue
adaptations in pregnancy associated with uncomplicated spontaneous
vaginal delivery using anatomical and biological outcomes.
STUDY DESIGN: Nulliparous gravidas were prospectively enrolled in

the first trimester at 2 institutions. Demographic and delivery data

were chart abstracted. Vaginal elastase activity (units per milligram
of protein) and Pelvic Organ Prolapse Quantification measurements
of pelvic organ support were obtained in the first and third trimesters. A subset underwent 3-dimensional ultrasound measures of
levator hiatus. Uncomplicated spontaneous vaginal delivery (VD) was
defined as no cesarean, forceps, vacuum, shoulder dystocia, thirdor fourth-degree perineal laceration, or prolonged second stage
labor.
RESULTS: We enrolled 173 women in their first trimester, 50 of whom

had ultrasounds. Mean age was 25.5
5.5 years with a body mass
index of 28.0
7.3 kg/m2. Sixty-seven percent were white/Caucasian, 27% black/African American, and 6% Hispanic/Latina. Mean
delivery gestational age was 38.5
2.9 weeks, with 23% delivering
by cesarean and 59% achieving uncomplicated spontaneous VD.

Vaginal support changed significantly over trimesters with posterior

vaginal and hiatal relaxation, vaginal lengthening, and increased
levator hiatus area during strain. Women achieving uncomplicated
spontaneous VD demonstrated significantly greater relaxation on thirdtrimester Pelvic Organ Prolapse Quantification for anterior, apical, and
hiatal measures than those without uncomplicated spontaneous VD.
Higher first-trimester vaginal elastase activity was strongly associated
with uncomplicated spontaneous VD (geometric mean activity 0.289

0.830 U/mg vs e0.029
0.585 U/mg, P .009). Higher firsttrimester elastase, younger age, lower first-trimester body mass index, and more third-trimester vaginal support laxity in points C and GH
were predictive of VD success.
CONCLUSION: Significant maternal adaptations occur in the vagina
during pregnancy, presumably in preparation for vaginal delivery.
Greater adaptation, including vaginal descent and higher firsttrimester elastase activity, is associated with an increased likelihood
of uncomplicated spontaneous VD.

Key words: childbirth, delivery, elastase, maternal adaptations, pelvic

organ prolapse

Cite this article as: Oliphant SS, Nygaard IE, Zong W, et al. Maternal adaptations in preparation for parturition predict uncomplicated spontaneous delivery outcome. Am J
Obstet Gynecol 2014;211:xx-xx.

elvic oor disorders (PFD)

including pelvic organ prolapse,
urinary incontinence, and anal incontinence are common and costly conditions, with up to one quarter of all adult
women endorsing PFD symptoms.1
Pregnancy, delivery, and associated birth
injury are known risk factors for the later
development of PFDs. Lifetime risk of

suffering from at least 1 symptomatic

PFD increases with increasing parity,
although rst birth seems to have the
largest impact.2-8
Childbirth injury has long been
implicated as the inciting event in the
causal pathway of PFDs; however,
women exclusively delivering via cesarean section are also affected, suggesting a

more complex insult mechanism than

birth injury alone.3,6,8 The association
between maternal anal-rectal sphincter
injury and new-onset fecal incontinence
is perhaps the strongest existent data
linking birth injury with pelvic oor
dysfunction. Direct links between birth
injury and urinary incontinence and
pelvic organ prolapse are less clear.2,9

From the Division of Urogynecology, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR (Dr Oliphant);
Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT (Dr Nygaard); and Divisions
of Ultrasonography (Dr Canavan) and Urogynecology and Reconstructive Pelvic Surgery (Dr Moalli), Department of Obstetrics, Gynecology, and
Reproductive Sciences, and Magee-Womens Research Institute and Foundation (Drs Zong and Moalli), Department of Obstetrics, Gynecology, and
Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA.
Received March 20, 2014; revised June 5, 2014; accepted June 9, 2014.
This study was supported by an unrestricted grant from the Jewish Healthcare Foundation, Pittsburgh, PA.
The authors report no conict of interest.
Presented in oral format at the 34th Annual Scientic Meeting of the American Urogynecologic Society, Las Vegas, NV, Oct. 16-19, 2013.
Reprints not available from the authors.
0002-9378/$36.00  2014 Mosby, Inc. All rights reserved.  http://dx.doi.org/10.1016/j.ajog.2014.06.021

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Thus, our current understanding of the

relative contributions of pregnancy,
birth, and concurrent birth injury to the
development of PFDs is incomplete,
complicating efforts at prevention.
Limited prior work suggests that the
pelvic oor undergoes profound changes
during pregnancy, often described as
adaptations, presumably in preparation
for vaginal delivery. Specically, the vagina and its supportive tissues relax, as
evidenced by a progression of pelvic organ descent across trimesters and persistence of this descent postpartum.10-12
Animal models demonstrate antenatal
mechanical softening of the pelvic tissues,
with injury occurring when vaginal
distension exceeds the point of failure of
these preparatory tissue adaptations.13-16
Following injury, pathological tissue remodeling ensues, leaving tissues biomechanically weaker than their preinjury
state. Mouse models of pelvic organ
prolapse containing null mutations for
genes involved in elastin synthesis and
assembly show that vaginal birth may
predispose to pelvic organ prolapse by
altering the balance between matrix synthesis, particularly elastin bers, and
protease/elastase activation.17-19
Because our understanding of similar
maternal pelvic support adaptations in
preparation for vaginal birth in humans is
limited, we undertook this project to
quantify and compare maternal vaginal
support adaptations in nulliparas using
both anatomical (Pelvic Organ Prolapse
Quantication [POP-Q] examination,
levator hiatus dimensions) and biological
outcomes (vaginal elastase activity) and
to identify which specic maternal adaptations are associated with a uncomplicated spontaneous vaginal delivery.

M ATERIALS

AND

M ETHODS

Following institutional review board

approval, this study enrolled a cohort of
nulliparous gravidas in the rst trimester.
Participants were recruited from June
2011 through July 2012 at 2 academic
centers (University of Pittsburgh and
University of Utah) from a larger cohort
of women participating in larger, multisite perinatology trial, the Nulliparous
Pregnancy Outcomes StudyMonitoring
Mothers-to-be (nuMoM2b).

The purpose of the ongoing

nuMoM2b study is to explore the mechanisms and predictors of adverse pregnancy outcomes in rst pregnancies
and follows women from the rst
trimester through delivery, with study
visits during each trimester. Women
eligible for our ancillary study were 18
years of age or older, with an ultrasoundconrmed, single gestation between 8
and 13 weeks at the time of enrollment,
with no prior pregnancy lasting 20 or
more weeks, and planned both to deliver
at the study site hospital and remain
in the area for at least 1 year postpartum.
Exclusion criteria existent for the
parent study included no history of 3 or
more spontaneous abortions, no known
lethal fetal anomaly, no known fetal
aneuploidy, no use of donor oocytes for
conception, no history of multifetal
reduction, and no participation in a
conicting maternal-fetal intervention
study. Following enrollment in the
parent study, women were approached
for enrollment in this ancillary project.

Clinical data
During study visits in the rst and third
trimesters, study investigators or trained
pelvic oor research nurses performed
pelvic examinations to measure vaginal
support using the POP-Q examination
as described by Bump et al.20 The parent
study collected extensive demographic,
health, and obstetric data for each subject. Our analysis included the baseline
demographics and delivery variables
collected via medical record and parent
study chart abstraction.
Elastase activity assay
At the rst- and third-trimester visits, we
collected vaginal uid swabs from the
posterior and lateral fornices to obtain
vaginal epithelial cells. After collection,
vaginal uid swabs were processed, the
supernatant collected, and the protein
concentration determined using the BioRad Protein Assay (Bio-Rad Laboratories, Hercules, CA). Halt proteinase
inhibitor cocktail (Thermo Fisher Scientic, Pittsburgh, PA) was added to
each sample to preserve proteinase activity. An EnzChek elastase assay kit (Life
Technologies, Grand Island, NY) was

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used to test each sample. This kit contains proprietary DQ elastin labeled with
BODIPY FL dye in which the uorescence has been quenched in the undigested form. When digested by elastase
or other proteases that exhibit elastaselike activity, highly uorescent particles
are yielded. This uorescence is proportional to the amount of elastase
activity in the sample and measured at an
excitation wavelength of 485 nm and an
emission wavelength of 530 nm using a
Molecular Devices SpectroMax M2
(Sunnyvale, CA).
Data were analyzed using a
4-parameter regression curve (Masterplex ReaderFit; Miraibio, San Francisco,
CA) of puried elastase from pig
pancreas and expressed as units per
milliliter total elastase, in which 1 unit
is dened as the amount of enzyme
necessary to solubilize 1 mg of elastin in
20 minutes at pH 8.8 and 37 C. Values
are then normalized to protein concentration to yield a nal elastase activity
value expressed as units of elastase per
milligram of protein. We chose to use
this noninvasive method to reect the
levels of elastase in the vagina because we
previously have found that the levels of
active matrix metalloproteinases in
vaginal swabs are highly correlated with
those in full-thickness vaginal biopsies
(obtained from the vaginal apex) in both
humans (Spearmans rho 0.92, P <
.001) and rhesus macaque monkeys
(Spearmans rho 0.92, P .05) (data
not shown and P. Moalli, personal
communication).

Transperineal ultrasonography
A subset of consecutive women at one
site also underwent ultrasound measures
of the levator hiatus in the rst and
third trimesters using transperineal
3-dimensional (3-D) technique ultrasound at rest and with maximal strain
(Valsalva) as described by Dietz.21
Transperineal ultrasound was performed
by a single unblinded examiner using a
Philips IU22 (Philips, Andover, MA)
with a 3D6-2 probe with the subject in
the lithotomy position and the hips
slightly exed and abducted. The subject
was maintained parallel to the oor
with no more than a 30-degree incline.

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TABLE 1

Maternal vaginal support changes first to third trimester

First
trimester

Variable

Third
trimester

Change
first to third
trimester

P valuea

POP-Q points
n

173

149

149

Aa

e2.3
0.7

e2.3
0.7

0.1
0.9

.131

Ba

e2.3
0.8

e2.3
0.7

0.1
0.9

.084

e6.0
1.3

e6.7
1.2

e0.6
1.7

< .001

e8.0
1.4

e8.5
1.2

e0.5
1.7

.001

Ap

e2.7
0.5

e2.5
0.4

0.2
0.5

< .001

Bp

e2.7
0.6

e2.5 (
0.4)

0.2 (
0.7)

.008

TVL

8.7
1.4

9.2 (
1.1)

0.5 (
1.5)

< .001

GH

2.5
0.6

2.8 (
0.6)

0.3 (
0.7)

< .001

PB

4.3
0.7

4.4 (
0.8)

0.1 (
0.9)

.309

Levator hiatus dimensions:

3-D ultrasound
n

50

41

50

Rest
Circumference, mm
Area, mm

139.0
19.6

143.2
18.6

4.2
14.9

1349.5
360.7 1423.0
328.4 73.5
285.2

.082
.111

Valsalva
Circumference, mm
Area, mm

144.6
20.0

153.3
22.5

8.7
18.0

1526.5
405.5 1722.9
531.5 196.4
413.9

.004
.005

Data are expressed as mean
SD.

R ESULTS

3-D, 3-dimensional; VD, vaginal delivery.

a

P values reflect paired comparisons for women with data at both time points (n 149).

Oliphant. Maternal adaptations for uncomplicated delivery. Am J Obstet Gynecol 2014.

The plane of minimal hiatal dimensions

was identied on 2-dimensional ultrasound as the minimal distance between
the hyperechogenic posterior aspect of
the pubic symphysis and the hyperechogenic border of the pubovisceral
muscle at the anorectal angle from 10
mm below to 12.5 mm above the plane
of minimal hiatal dimensions. The levator ani were identied in the midsagittal, coronal and axial planes. Images of
the levator ani obtained at rest and with
maximal strain (Valsalva) utilizing 3-D
imaging were used to calculate the levator hiatus circumference and area.

Statistical analyses
We assessed changes in pelvic organ support by POP-Q, levator hiatal dimensions

a complicated delivery. Deliveries prior

to 24 weeks gestation were excluded
from delivery group analysis. Because we
had no data on which to base a sample
size calculation for these specic analyses, our sample size was determined by
feasibility. With limited funding, we
were able to enroll 173 women who were
also enrolled in the parent study.
Measures for pelvic organ support
by POP-Q, levator hiatal dimensions by
3-D ultrasound, and elastase activity were
compared between delivery groups. A
Student t test, paired t test, c2 test, or their
nonparametric equivalents were utilized
as appropriate for paired and group
comparisons. Forward logistic regression
modeling was utilized to model predictors of uncomplicated spontaneous
VD. Variables with values of P < .2 from
the univariate analysis were inserted into
the model. Additionally, we chose to
control for body mass index (BMI) at the
time of collection of vaginal swab, as is
standard for biological assays, and for
specic gestational age at the time of
collection. The values of elastase were log
transformed for analysis presentation.
Data analysis was performed using IBM
SPSS, version 20.0 (Armonk, NY), and
P < .05 was considered signicant.

by 3-D ultrasound, and elastase

activity between trimesters using paired
comparisons. For the analysis of the
impact of maternal adaptations on delivery outcome, we utilized a composite
outcome for uncomplicated spontaneous vaginal delivery (VD).
Women were categorized as having an
uncomplicated spontaneous VD if they
met all of the following criteria: delivery
without cesarean, operative vaginal delivery (forceps or vacuum), shoulder
dystocia, third- or fourth-degree perineal laceration; and length of the second
stage labor of 120 minutes or less
without regional anesthesia or 180 minutes or less with regional anesthesia.
Women who did not meet at least one of
these criteria were categorized as having

From the parent cohort, we enrolled 173

nulligravidas in the rst trimester pregnancy. Study data were available for 149
(86%) at the third trimester and 150
(87%) at delivery. A subset of 50 women,
consecutively enrolled from the University of Pittsburgh site, underwent ultrasounds in the rst trimester with 41 of
these women completing the thirdtrimester scans. The mean age of the
study participants at enrollment was
25.5
5.5 years with a prepregnancy
BMI of 28.0
7.3 kg/m2. Sixty-seven
percent were identied as white/Caucasian, 27% black/African American, and
6% Hispanic/Latina. Mean gestational
age at delivery was 38.5
2.9 weeks with
a mean birthweight of 3285
506.9 g.
Forty-one percent of the women did
not achieve our denition of uncomplicated spontaneous VD, with 40 undergoing cesarean (27%), 11 undergoing
operative delivery (7%), 16 having a

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TABLE 2

Univariate comparisons in women with and without uncomplicated

vaginal delivery
Variable

Uncomplicated
spontaneous
VD, yes

Uncomplicated
spontaneous
VD, no

P valuea

Demographic,
n 150

Age, y
First-trimester BMI,
kg/m2

25.8
5.4
26.8
6.6

28.1
5.4
29.3
7.5

.010
.037

Delivery
n 149
n 145

Gestational age, wks

Birthweight, g

38.7
1.9
3241.8
57.4

38.9
2.2
3352.2
572.9

.760
.201

Ba

e2.2
0.8

e2.4
0.5

.019

e6.5
1.1

e7.1
1.3

.002

e8.3
1.2

e8.9
1.2

.016

Bp

e2.5
0.4

e2.6
0.4

.153

TVL

9.2
1.0

9.6
1.2

.019

GH

2.9
0.7

2.6
0.5

.004

PB

4.4
0.8

4.4
0.9

.963

Circumference, mm

145.2
19.9

140.5
17.4

.449

1430.4
337.8

1416.9
335.6

.902

Circumference, mm

153.4
21.5

152.1
24.8

.862

1697.8
496.6

1733.4
600.5

.841

Third-trimester
POP-Q (n 140)

Levator hiatus
dimensions: third
trimester (n 39)

Rest
Area, mm
Valsalva
Area, mm

Data are expressed as mean
SD.

BMI, body mass index; POP-Q, Pelvic Organ Prolapse Quantification; VD, vaginal delivery.
a

P values reflect group comparisons of means.

Oliphant. Maternal adaptations for uncomplicated delivery. Am J Obstet Gynecol 2014.

second-stage labor longer than 120 minutes without regional anesthesia or

longer than 180 minutes with regional
anesthesia (11%), 5 experiencing
shoulder dystocia (3%), and 2 experiencing third- or fourth-degree perineal
lacerations (1%). Documented primary
indications for delivery by cesarean
included failure of labor induction or
arrest of dilation/descent (n 19),
nonreassuring fetal status (n 9), malpresentation (n 6), and other (n 6).
Two of these cesarean deliveries were
performed after a failed attempt at
operative delivery.
Changes in POP-Q scores across
trimesters demonstrated worsening posterior support, widening of the genital
hiatus, and overall vaginal lengthening
(Table 1). Mean levator hiatus area with

maximal strain (Valsalva) increased

across trimesters, whereas the area at rest
did not signicantly change. Women
achieving uncomplicated spontaneous
VD were slightly younger than their
complicated delivery cohorts and
demonstrated greater vaginal relaxation
on third-trimester POP-Q points,
reecting anterior, apical, and hiatal
support. No differences in third-trimester
ultrasound measures were seen between
delivery groups. Table 2 lists univariate
analyses of demographic, delivery, and
pelvic support measure variable associations by uncomplicated spontaneous VD
group.
Elastase activity data were available
from 160 rst-trimester and 147
third-trimester samples. The geometric
mean elastase activity level in the rst

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trimester was 0.130
0.728 U/mg and

0.142
0.550 U/mg in the third
trimester. There was no signicant difference in elastase levels from the rst to
the third trimester when compared
within subjects (geometric mean change,
e0.001
0.850 U/mg, P .989). Higher
rst-trimester elastase activity was associated with uncomplicated spontaneous
VD, with geometric mean activity of
0.289
.831 U/mg in the uncomplicated
spontaneous group vs e0.029
0.586
U/mg in those with a complicated delivery (P .009).
No further association was found between third-trimester elastase activity
and uncomplicated spontaneous VD,
with geometric mean activity of 0.157

0.571 U/mg in the uncomplicated
spontaneous VD group vs 0.120
0.532
U/mg in the complicated delivery
group (P .70), indicating that altered
elastin metabolism occurred early in
pregnancy and preceded POP-Q
changes.
The Figure shows distributions of
rst-trimester logarithmic elastase activity by delivery group. Women with
higher rst-trimester elastase activity
were more likely to achieve uncomplicated spontaneous VD, with an adjusted
odds ratio of 2.5 (95% condence interval, 1.3e5.0) for a 1 log increase in
rst-trimester elastase activity (units per
milligram) in our logistic regression
model. Final model results (Table 3),
controlling for gestational age at the time
of sample collection, demonstrated
higher elastase activity in the rst
trimester, younger age, lower rsttrimester BMI, and increasing vaginal
laxity in POP-Q points C and GH to be
associated with VD success.
We performed sensitivity analyses
excluding 17 women undergoing cesarean delivery for an indication other than
arrest (as primary or secondary documented indication). These analyses were
consistent with our primary ndings,
demonstrating signicantly higher
rst-trimester geometric mean elastase
activity in those with uncomplicated
spontaneous VD (0.289
0.831 U/mg)
vs those with an complicated delivery
(0.019
0.610 U/mg, P .044) and no
signicant differences between groups

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C OMMENT

FIGURE

Boxplot of first-trimester logarithmic elastase activity (units per

milligram) by successful vaginal delivery group

Oliphant. Maternal adaptations for uncomplicated delivery. Am J Obstet Gynecol 2014.

in third-trimester geometric mean elastase activity, change in elastase activity

between trimesters, or third-trimester
levator hiatus ultrasound measures.

Sensitivity analyses showed similar

ndings in third-trimester POP-Q
points, with greater vaginal relaxation in
anterior, apical, and hiatal support.

TABLE 3

Logistic regression model: predictors of uncomplicated spontaneous

vaginal delivery (n [ 128)
Variable

Adjusted odds ratio

(95% confidence interval)

First-trimester logarithmic elastase activity

2.422 (1.224e4.792)

.011

First-trimester BMI

0.905 (0.848e0.966)

.003

Gestational age at collection, wks

0.807 (0.592e1.098)

.173

Age

0.875 (0.802e0.956)

.003

Third-trimester POP-Q point C

2.093 (1.361e3.218)

.001

Third-trimester POP-Q point GH

4.115 (1.866e9.074)

< .001

P value

Model controlled for first-trimester BMI and gestational age at time of first-trimester vaginal swab collection. In addition, all
variables with P < .20 found in Table 2 were included for consideration in model building. The previously mentioned variables
represent our final model.
BMI, body mass index; POP-Q, Pelvic Organ Prolapse Quantification.
Oliphant. Maternal adaptations for uncomplicated delivery. Am J Obstet Gynecol 2014.

Our data suggest that signicant maternal adaptations occur during pregnancy
in preparation for vaginal birth. These
adaptations are evidenced by POP-Q
changes over trimesters, suggesting overall vaginal lengthening, hiatal widening,
and posterior vaginal relaxation. Similarly, ultrasound measures of levator hiatal dimensions demonstrated hiatal
widening at maximal strain across trimesters. We found rst-trimester elastase
levels to be strongly associated with uncomplicated spontaneous VD.
The importance of early elastase activity in the delivery process suggests that
the remodeling process occurs quite
early in pregnancy. In a model controlling for age, rst-trimester BMI and
sampling time, apical and genital hiatus
relaxation in late pregnancy as measured
by POP-Q and higher elastase activity in
rst trimester were each strongly and
independently associated with vaginal
delivery success.
Many studies have reported an association between vaginal delivery and pelvic
organ prolapse.6,9,22 Although this association has been attributed largely to the
delivery event, it is possible that vaginal
delivery is on the causal pathway between
vaginal descent during pregnancy and
pelvic organ prolapse. In this instance,
some of the risk attributed to the delivery
event could be due to the fact that
women with more vaginal descent during
pregnancy are more likely to deliver
vaginally.
The degree of POP-Q support change
seen across trimesters in this cohort,
although statistically signicant, may lack
immediate clinical signicance because
of the small degree of overall change.
However, we do not fully understand the
long-term ramications of this support
alteration on future pelvic oor health.
Animal data have demonstrated a relative
suppression of elastase during pregnancy
followed by a postpartum surge, presumably for tissue recovery and repair.23
Whether such a surge is identied in
humans is the focus of future study.
Our study is unique in that we used a
combination of biological and clinical
data to explore pelvic support in human

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pregnancy, thus providing a needed
groundwork for future work in this area.
Although this study is exploratory, our
population enrolled at 2 sites exhibits
reasonable diversity. However, we were
able to perform ultrasound evaluation
on only a subset of women because of
funding constraints. A smaller sample
for ultrasound data may in part explain
a lack of association between levator hiatus measures and our composite
outcome of uncomplicated spontaneous
VD.
Alternatively, the data may suggest
that remodeling of the vagina and its
supportive tissues is more critical for an
uncomplicated spontaneous vaginal delivery then hiatal widening. We are
limited in our ability to fully describe
maternal adaptations because our rst
data collection occurred in the rst
trimester and not before conception;
although ideal, pregestational data
collection is likely not feasible in an
observational cohort of this nature.24
Another notable limitation is that the
parent study included women with prior
pregnancies lasting less than 20 weeks
gestation and those with prior cervical
surgeries, both of which have the potential for unmeasured impact on tissue
adaptations in the current pregnancy.
We are able to measure only the relationship of the variables included in our
data collection and analysis; thus, we
may not have captured all relevant
contributing factors.
Because this is a preliminary study, we
chose to include all cesarean deliveries in
the complicated delivery group, and it is
biologically plausible that the same adaptations that inhibit vaginal delivery
might also predispose to nonreassuring
fetal status (for example, by descent
against a too tight outlet). Including these
cesarean deliveries, if in fact there is no
association between elastase and nonreassuring fetal status, breech, or other
indications other than arrest of descent/
dilatation, would bias our results toward
the null hypothesis. Thus, the magnitude
of the true effect may be greater than we
observed, which is supported by our
sensitivity analyses. In addition, we did
have missing data at various time points,

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a limitation common in longitudinal
cohort designs, although overall subject
retention was high.
Future work is needed to further
explore how maternal adaptations affect
uncomplicated spontaneous vaginal delivery. The ability to distinguish women
most likely to deliver atraumatically via
uncomplicated spontaneous vaginal
birth has the potential to have a great
impact on obstetrical care, perhaps
guiding mode of delivery counseling, the
site of delivery, operative delivery practices, and maternal and provider expectations for the delivery event.
In the long term, increased understanding of these maternal adaptations
may allow for injury prevention strategies
to reduce the future incidence of symptomatic pelvic oor disorders. Further
human studies are needed to understand
the role of elastase and other biomarkers
in pregnancy adaptations, postpartum
recovery, and the subsequent development of pelvic oor disorders.
ACKNOWLEDGMENTS
We thank the nuMoM2b (NCT01322529) for
their support and assistance of this ancillary
project and Leslie Meyn, PhD, of the MageeWomens Research Institute and Foundation,
for her assistance with statistical analysis.

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