Overview: Impact of Pregnancy and Birth on Pelvic Floor Dysfunction; Preventing Pelvic Floor Problems

If you’ve heard about pelvic floor problems related to pregnancy and giving birth, you may be confused about what they are and what can cause them.


What are pelvic floor problems?

Many women experience pelvic floor dysfunction around the time of birth and/or later in life. Pelvic floor problems include leaking urine (urinary incontinence), leaking gas or — more rarely — feces (bowel incontinence), sexual dissatisfaction, and a sagging of the inner organs (uterine and other pelvic organ prolapse). It is important for every woman to understand what she can do to keep her pelvic floor strong and protect it from injury.

Separating fact from fiction: what causes pelvic floor dysfunction?

These days, there is a lot of conflicting and confusing information about the cause of pelvic floor dysfunction. Vaginal birth has been blamed, and some suggest that enlarging the opening of the vagina by cutting it at the time of birth (episiotomy) or even having a surgical birth when there is no medical complication (elective c-section) will prevent weakened pelvic floor muscles and injury. Unfortunately, there is a lot of false, unproven, and incomplete information on this topic.

This article provides reliable, research-based information about pelvic floor dysfunction, including steps you can take to keep your pelvic floor muscles healthy and strong.

What is the “pelvic floor”?

The pelvic floor is a complex, multilayered group of muscles and surrounding tissue that are suspended like a hammock between your pubic bone in front and the base of your spinal column in back. The pelvic floor supports your bladder, rectum, uterus, and other internal organs. Bands of pelvic floor muscles surround your vagina, your anus, and the tube that carries urine from your bladder (urethra). The tissue between your vagina and anus is called your perineum.

What problems can arise from weakened or injured pelvic floor muscles?

A healthy pelvic floor keeps the pelvic organs in their proper place and the muscles that close the bladder and anus functioning normally. With a weakened pelvic floor, the uterus or other organs may sag (prolapse). Weakness and injury also make it more difficult for the bladder muscle to stay closed during sudden increases in abdominal pressure, such as while coughing, laughing, sneezing, or lifting a heavy object. This can result in leaking urine (urinary stress incontinence). A weak pelvic floor can lower sexual satisfaction during intercourse because satisfaction for both partners often depends on good tone in the muscles surrounding the vagina. Finally, injury to the band of muscle around the anus can result in leaking gas, a sense of urgency about elimination, or, less commonly, leaking feces (bowel incontinence).

What factors can cause pelvic floor dysfunction?

Many factors affect pelvic floor strength, including some that do not relate to childbirth. For example, heavy women are much more likely to experience urinary stress incontinence than women who are at average or below-average weight for their height. Other non-maternity factors that appear to increase risk for pelvic floor dysfunction include smoking (probably because it leads to excess coughing), use of hormone replacement therapy (HRT), and having a hysterectomy (surgical removal of the uterus).

A number of factors appear to play a role during pregnancy and childbirth. The extra weight and pressure of the baby, the “bag of waters”, and the placenta causes many women to experience urinary incontinence by the end of pregnancy.

A number of practices increase risk during childbirth. When giving birth, many pregnant women in  S.A (particularly in private hospitals) experience two interventions that increase risk for pelvic floor dysfunction:

  • continuous electronic fetal monitoringto keep track of the baby’s heart rate (being connected to this monitor throughout labor vs. monitoring at regular intervals)
  • epidural analgesiafor relieving labor pain (vs. many other drug and drug-free measures for pain relief).These increase risk by increasing the likelihood of other interventions that can injure your pelvic floor: having a vacuum extraction or forceps delivery, which are often used hand-in-hand with episiotomy.

Several practices that may be used with vaginal birth at the time of pushing increase the likelihood of pelvic floor injury. Interventions that increase risk for pelvic floor injury at this time include:

  • lying on the back(supine position) or on the back with legs in stirrups (lithotomy position) for pushing and giving birth; this works against gravity, yet is used with most births in S.A
  • episiotomy:cutting the back of vaginal opening to enlarge it for birth, a common procedure with vaginal birth in S.A
  • assisted vaginal birth:using vacuum extraction or forceps to help bring the baby out
  • caregiver-directed pushing(sometimes called “purple pushing”): women are directed to bear down as long and hard as they can during contractions once the opening of the uterus (cervix) is fully stretched (dilated); this common practice can be far more forceful than when a woman’s own natural pushing reflexes move the baby out; as discussed on other pages in this section, evidence for harm is less clear than for other practices in this list, yet it would be prudent to avoid this practice
  • fundal pressure:a member of the medical team presses on the woman’s abdomen to help move the baby out.

Are these obstetric interventions necessary?

Rates of using these practices vary widely among caregivers and hospitals in South Africa. Many women experience several of these interventions as common or routine practices when giving birth, yet no studies appear to have found an advantage to routine or frequent use of any of them. A doctor or midwife with a conservative practice style recognizes the risks and use them only when they offer a clear benefit. For example, assisted vaginal delivery can help a baby who needs to be born quickly, or can help to avoid a c-section. Practitioners with a conservative practice style may rarely, if ever, use such practices as fundal pressure.

Careful choice of your doctor or midwife and choice of your birth setting can help you avoid risks of these and other unnecessary and potentially harmful practices and procedures. This is because in hospitals with established routines, it may be hard to get exceptions made. While it is your legal and ethical right to accept or refuse care, this right may be difficult or impossible to assert in busy settings with established routines.

Can vaginal birth in and of itself harm my pelvic floor?

It is increasingly common to hear that “vaginal birth” causes pelvic floor problems. However, a recent review of the research found no studies that attempted to avoid or limit use of the practices that can injure a woman’s pelvic floor listed above in order to determine whether vaginal birth itself plays a role. It is wrong to conclude at this time that vaginal birth is the cause of pelvic floor dysfunction.

Is “vaginal birth” the culprit in the high levels of female incontinence later in life?

Studies that take a longer view find that most new problems with urinary and bowel incontinence that appear after birth lessen over time and disappear during the postpartum recovery period. Few women experience frequent or bothersome symptoms beyond a few months after giving birth, and any differences between women who had cesarean sections and women who had vaginal births seem to disappear by the time of menopause. Older women experience high rates of incontinence, but this appears to be due to other factors. For example, excess weight, smoking, and the development of certain diseases play a role. Women who have never been pregnant appear to experience high rates of urinary incontinence in later years.

Would elective c-section prevent incontinence?

Cesarean section offers little protection against incontinence after the postpartum recovery period. Some women experience incontinence despite cesarean childbirth. Routine c-section would impose the broad range of risks associated with cesarean section on many while preventing ongoing and generally mild symptoms of incontinence in a few women per hundred about a year after giving birth. Current research suggests that planned (elective) c-section offers no protection against experiencing incontinence beyond age 50 or so. Due to the many extra risks of surgical birth, the wisest strategy for safe childbirth is to plan for vaginal birth with minimal use of harmful practices. Moreover, performing pelvic floor exercises (kegel exercises) in pregnancy can help prevent urinary incontinence.

For those few women who continue to experience bothersome incontinence after childbirth, treatments are available, ranging from kegel exercises (which can be tried at any time) to surgery. Few women will experience the risks of having a surgical procedure if surgery is reserved as a last resort for serious problems lasting at least a year.

When there is no clear, compelling and well-supported medical need for surgical birth, the best choice is a vaginal birth that avoids use of practices and procedures that may contribute to pelvic floor dysfunction.

Source: adapted (to south african context) www.childbirthconnection.com 200725