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Pelvic Floor Disorders and Method of Childbirth

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By ANaturalAdvocate

The October issue of The Green Journal includes a new article about pelvic floor disorders and method of childbirth. Many women say that fear of incontinence impacts their approach to childbirth, with some women choosing elective Cesareans specifically to prevent pelvic floor damage. The article, with Dr. Victoria L. Handa as lead author, discusses whether these concerns are accurate, and how they might impact method of childbirth.

The study looked at women 5-10 years after their first delivery, all of whom had delivered at Greater Baltimore Medical Center, classifying each woman by method of delivery:

  • cesarean without labor
  • cesarean during active labor
  • cesarean after complete cervical dilation
  • spontaneous vaginal delivery
  • operative vaginal delivery [including forceps and vacuum extraction]

If a woman had deliveries that fit into more than one category, she was classified according to the method of delivery that the authors felt had the highest likelihood of causing pelvic floor injury. The classification was determined by a review of obstetrical discharge records.

The authors then measures rates of four types of pelvic floor injury:

  • stress incontinence
  • overactive bladder
  • anal incontinence
  • prolapse (defined as at or beyond the hymen)

The injuries were first assessed through questionnaires given the women in the study, and then confirmed or re-assessed through physical examination. In addition, women who had undergone surgery or prior or current therapy for a specific pelvic floor disorder were considered as having it, even if they did not currently show symptoms. 

The authors also looked at race (self-reported), maternal age at first delivery, obesity (measured by BMI at study enrollment), and cigarette smoking (“classified as ‘never’ or ‘ever’ based on whether a woman had smoked at least 100 cigarettes in her life”).

The authors concluded that a woman who had had at least one vaginal birth was “significantly more likely” to report stress incontinence or prolapse, but that “the most dramatic risk was associated with operative vaginal birth.” Symptoms of prolapse were uncommon across all groups but interestingly only 19% of women with prolapse reported “bothersome symptoms” from the prolapse; women who were obese upon examination or over age 35 at time of first delivery were more likely to report symptoms. The authors hope to continue to follow the women to determine whether those with reportable symptoms of prolapse were more or less likely to progress or regress. 

Anal incontinence and overactive bladder were also both “significantly associated” with operative vaginal delivery but not spontaneous vaginal birth.

The authors found no difference in the rates of pelvic floor disorders in the cesarean groups, which is interesting considering that previous studies had indicated a link between active labor before a cesarean and pelvic floor injury. They did indicate, however, that the rate in each group was so small that an increase may not have been detectable under a doubling of the odds.

The study was limited by the small number of pelvic floor injuries in the group as a whole, and the low participation rate (50%) of all eligible women (based on medical records). “In addition, this is an observational study and we therefore cannot with certainty ascribe the incidence of pelvic floor disorders to obstetric events. We cannot exclude the possibility that unmeasured characteristics of the population or other exposures were relevant to the development of pelvic floor disorders.”


What do you think? What information did you have regarding possible pelvic floor disorders before giving birth? The authors state that they hope the study - which will continue looking at the cohort over time - “will be useful to women and their obstetric providers as they weigh childbirth options.” Does the information in this study impact how you view various methods of childbirth? What would make you change your mind, if anything, regarding pelvic floor disorders and childbirth? What other factors do you think might impact the rate?


Edited to add the chart showing exact numbers and percentages of pelvic floor disorders by childbirth method, race, age, parity, body mass, and smoking.

Chart courtesy of The Green Journal.

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Reader Comments (21)

I wish there were a pithy unnecesarean-style phrase for "unnecessary forceps delivery," because I'm still pissed about it a year later. Mostly when I run.

October 17, 2011 | Unregistered CommenterKylie

I wish they gave actual numbers on the occurrance of these problems. You know, if 50% of women are soaking their pants every time they sneeze after a vaginal birth, that is significant. But if it is 0.05% who have a slight bit of wetness when they sneeze...well sheesh, what are we all up in arms about? I've heard that "anal incontinence" can actually just mean inability to controllable farting. Certainly not socially pleasing...but when I compare it to the risks of cesarean, I'd opt for that.

October 17, 2011 | Unregistered CommenterKnitted in the Womb

There's a huge body of research out there on this subject. Unfortunately not many people seem all that interested in sharing it with women before these problems occur, when they can still consider their risks and make appropriate choices.

It's really a drag to be forced into natural childbirth when it's something that has little or no value to you depending on your beliefs, and ending up with a nightmare of problems that significantly impact your life and could pretty easily have been avoided had you a) been completely informed and b) been given the autonomy to make your own decisions based on your own preferences and risk tolerance.

Having a significant PFD can be the beginning of many years of shame, humiliation, and pain. It can limit your ability to participate in sports and can affect your intimate relations. You can emerge from childbirth thinking that you've escaped surgery only to find yourself facing a never-ending ordeal of invasive exams and surgeries-- only these aren't limited to your abdomen. I believe a recent study suggested that something like 1 in 10 women will undergo surgery for these problems during her lifetime.

Thanks for drawing some attention to the topic.

October 17, 2011 | Unregistered CommenterYttrbia

Knitted in the Womb: The study actually does have the numbers; I will update the post with them now.

October 17, 2011 | Registered CommenterANaturalAdvocate

I just wish that they would adjust for women who did or did not do their kegels. I did mine and yeah, right after birth, I'd have a little wetness, but just kept on with the kegels and by two months later, right back to normal. But what if you never keep working at the exercises and just have 3 kids back to back? I don't know how much that affects it.

October 17, 2011 | Unregistered CommenterC

I have been a pre and post natal exercise specialist for 15 years. Since the birth of my first child I have changed how I train women during their pregnancies. This is my story on Pelvic floor issues http://pregnancyexercise.co.nz/information/pregnancy/how-much-pelvic-floor-muscle-exercise

October 17, 2011 | Unregistered CommenterLorraine Scapens

I wish someone would study the incidence of pelvic floor injuries comparing methods and positions of pushing. I am inclined to believe that forcing a woman onto her back (or even the c-curl) and/or urging her into valsalva-style pushing increases the likelihood of pelvic floor damage. It would be nice to have some research to back up that belief and then compare those figures to ones from a study such as they above.

October 18, 2011 | Unregistered CommenterAron

Pelvic floor muscle exercises (kegels) can be helpful, but they're never going to do much for women with more extensive injuries. Building up some muscle strength can't compensate for significant tears or damage to connective tissue, muscles, or nerves.

I know it's fashionable to blame these problems on obstetrical technique, but I can't think of any reason to believe that any particular pushing position would be protective.

October 18, 2011 | Unregistered CommenterYttrbia

I know it's fashionable to blame these problems on obstetrical technique, but I can't think of any reason to believe that any particular pushing position would be protective.

Well, that's revealing language. It assumes that these injuries were an inevitable* risk of vaginal birth and assumes the current level of risk is inherent to vaginal birth. Thus some "other" position(s) might be "protective." Rather than that the most typical position(s) in US hospitals carries an increased risk over mothers being allowed to choose whatever feels most comfortable, waiting for the pushing urge (when possible), etc. Not to say that we have hard data on this, but just saying that the choice of words was revealing of a bias (meant neutrally, as we all have biases). The assumption that the current "standard" is some sort of gold standard-- and this hardly applies only to birth-- is really faulty and dangerous. Especially when the above statement implies that we don't know whether it is gold or not. If we don't know, then how is the assumption that it is gold any more valid than that it is harmful? Aside from a bias towards authority figures and tradition, which makes little sense given the known history of obstetrics-- and medicine, and anything, for that matter. And I say that in as neutral and factual a way as possible. Even if we give some credit to authority and tradition, it's hardly the final word on the matter.

I apologize if I missed this, but I am running out the door-- but where is episiotomy in all this? Without more information, I must assume that having an episiotomy did not preclude inclusion in the "non-operative" vaginal delivery group. Or did it?

I think it's really important to make women aware of ALL of the risks of EVERY choice that can be made in childbirth. To act like one choice is risk-free and the other is not is insulting and injurious, whatever those choices may be, and however necessary they may be or one may feel they are.

*Surely some percentage is-- whatever that percentage may be.

October 18, 2011 | Unregistered CommenterDreamy

Oh, and FWIW, I don't think kegels have been shown definitively to do much, on the whole, when looking at any cohort of significant size. Though if anyone wants to show me the studies, I'd be happy to read them.

October 18, 2011 | Unregistered CommenterDreamy
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