Preventing Pelvic Floor Dysfunction: What You Need to Know
What are pelvic floor problems?
Separating fact from fiction: what causes pelvic floor dysfunction?
What is the "pelvic floor"?
What problems can arise from weakened or injured pelvic floor muscles?
What factors can cause pelvic floor dysfunction?
Are these obstetric interventions necessary?
Can vaginal birth in and of itself harm my pelvic floor?
Is "vaginal birth" the culprit in the high levels of female incontinence later in life?
Would elective c-section prevent incontinence?
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. This section of the website provides reliable information
about these problems and how to avoid them.
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.
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
This Pregnancy Topic provides reliable, research-based
information about pelvic floor dysfunction, including steps you can
take to keep your pelvic floor muscles healthy and strong.
Here you can learn about:
- causes of weak pelvic floor muscles and pelvic floor dysfunction, including whether episiotomy or elective c-section will protect your pelvic floor in Options: Pelvic Floor
- risks of some labor and birth practices and benefits of kegel exercises, based on results of the most relevant and better quality research in Best Evidence: Pelvic Floor
- tips for keeping your pelvic floor muscles strong and preventing pelvic floor dysfunction during pregnancy, during and after birth, and throughout your life in Tips & Tools: Pelvic Floor
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 (see diagram
below). 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.
Pelvic Floor Anatomy
©1981 Sheila Kitzinger and National Childbirth Trust.
Used with permission.
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). See diagram above.
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).
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.
number of practices increase risk during childbirth. When giving birth,
most pregnant women in the U.S. experience two interventions that
increase risk for pelvic floor dysfunction:
- continuous electronic fetal monitoring to keep track of the baby's heart rate (being connected to this monitor throughout labor vs. monitoring at regular intervals)
- epidural analgesia for 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.
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 the U.S.
- episiotomy: cutting the back of vaginal opening to enlarge it for birth, a common procedure with vaginal birth in the U.S.
- 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.
Learn more about how these obstetric practices relate to pelvic floor dysfunction in Options: Pelvic Floor.
of using these practices vary widely among caregivers and hospitals in
the United States. 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
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.
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
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 (see Best Evidence: C-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.
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.
© 2013 Childbirth Connection. All rights reserved.
Childbirth Connection is a national not-for-profit organization founded in 1918 as Maternity Center Association. Our mission is to improve the quality of maternity care through research, education, advocacy and policy. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families.
Most recent page update: 2/28/2011