EDITORS’ CHOICE Pelvic floor morbidity up to one year after difficult instrumental delivery and cesarean section in the second stage of labor: A cohort study Rachel E. Liebling, MRCOG, a, * Rebecca Swingler, MB, ChB, a Roshni R. Patel, MRCOG, b Lisa Verity, MRCOG, c Peter W. Soothill, MD, FRCOG, b Deirdre J. Murphy, MD, MRCOG d Royal United Hospital, Bath a ; Division of Obstetrics and Gynaecology, University of Bristol, b St. Michael’s Hospital, Bristol; Derriford Hospital, Plymouth c ; Ninewells Hospital and Medical School, University of Dundee, d United Kingdom Received for publication September 19, 2003; revised November 10, 2003; accepted January 8, 2004 – Objective: This study was undertaken to assess symptoms of pelvic floor morbidity at 6 weeks and at 1 year after difficult instrumental vaginal delivery or cesarean section during the second stage of labor. Study design: Prospective cohort study of 393 women with term, singleton, cephalic pregnancies who required operative delivery in surgery at full dilatation between February 1999 and February 2000. Postal questionnaires were used for follow-up at 6 weeks and at 1 year. Results: Instrumental delivery was associated with a greater risk of urinary incontinence at 6 weeks and at 1-year postdelivery, adjusted odds ratio [OR] 7.8 (95% CI, 2.6-23.6) and OR 3.1 (95% CI, 1.3-7.6), respectively. Although instrumental delivery was associated with an increased risk of moderate-to-severe dyspareunia at 6 weeks, adjusted OR 3.35 (95% CI, 1.36-8.25), this difference was not significant at 1 year. Cesarean section after attempted instrumental delivery was associated with an increased risk of moderate-to-severe pain during intercourse at 1 year compared with immediate cesarean section, (18% vs 9%) P = .01. Conclusion: Although cesarean section at full dilatation does not completely protect women from pelvic floor morbidity, those that followed instrumental delivery had a significantly greater prevalence of urinary symptoms and dyspareunia. Urinary symptoms persist up to 1 year after delivery. Ó 2004 Elsevier Inc. All rights reserved. KEY WORDS Maternal morbidity Pelvic floor morbidity Instrumental vaginal delivery Emergency cesarean section – Although the majority of women aim for spontane- ous vaginal delivery, a significant proportion fail to progress in the second stage of labor and are faced with a choice between a potentially difficult instrumental vag- inal delivery and cesarean section at full dilatation, each Financial support provided by The Mother and Baby Trust. * Reprint requests: Rachel Liebling, MRCOG, Women’s Health, Royal United Hospital, Combe Park, Bath BA1 3NG UK. E-mail: reliebling@hotmail.com American Journal of Obstetrics and Gynecology (2004) 191,4e10 www.elsevier.com/locate/ajog 0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.01.013