Because levator ani (LA) muscle injuries occur in approximately 13% of all vaginal births, insights are needed to better prevent them. In Part I of this paper, we conducted an analysis of the bony and soft tissue factors contributing to the geometric “capacity” of the maternal pelvis and pelvic floor to deliver a fetal head without incurring stretch injury of the maternal soft tissue. In Part II, we quantified the range in demand, represented by the variation in fetal head size and shape, placed on the maternal pelvic floor. In Part III, we analyzed the capacity-to-demand geometric ratio, g, in order to determine whether a mother can deliver a head of given size without stretch injury. The results of a Part I sensitivity analysis showed that initial soft tissue loop length (SL) had the greatest effect on maternal capacity, followed by the length of the soft tissue loop above the inferior pubic rami at ultimate crowning, then subpubic arch angle (SPAA) and head size, and finally the levator origin separation distance. We found the more caudal origin of the puborectal portion of the levator muscle helps to protect it from the stretch injuries commonly observed in the pubovisceral portion. Part II fetal head molding index (MI) and fetal head size revealed fetal head circumference values ranging from 253 to 351 mm, which would increase up to 11 mmupon face presentation. The Part III capacity-demand analysis of grevealed that, based on geometry alone, the 10th percentile maternal capacitypredicted injury for all head sizes, the 25th percentile maternal capacity coulddeliver half of all head sizes, while the 50th percentile maternal capacity coulddeliver a head of any size without injury. If ultrasound imaging could beoperationalized to make measurements of ratio g, it might be used tousefully inform women on their level of risk for levator injury during vaginalbirth.
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