What birth practices can affect the pelvic floor?

As detailed on the Research and Evidence page, various practices that are used around the time of birth can increase the risk of pelvic floor injury:

• Lying on the back (supine position) or on the back with legs in stirrups (lithotomy position) when pushing and giving birth (in women without epidurals). This is not ideal because it works against gravity, but it is still used with most births in the United States.
• Episiotomy, cutting the back of the vaginal opening to enlarge it for birth, is used with about one vaginal birth in ten in the United States.
• Vacuum extraction or forceps to help bring the baby out (also called assisted vaginal birth). There is growing agreement that selective, skillful use of assisted vaginal birth can help many women avoid a cesarean.
• Fundal pressure, when a health care professional presses on your belly to help move the baby out.

Another common practice – prolonged, forceful staff-directed pushing (versus pushing according to a woman’s own sensations and innate urge) – may cause injuries in women without epidurals, but further research is needed.

Two commonly used labor interventions can increase risk for pelvic floor problems because they increase the likelihood that the birth will involve vacuum extraction or forceps, possibly with episiotomy:

• Continuous electronic fetal monitoring to keep track of the baby’s heart rate; and
• Epidural analgesia for relieving labor pain (versus many other drug and drug-free measures for pain relief).

Rates of using the practices and procedures listed above vary depending on who your care providers are and where you give birth. Some are fairly common and often considered routine. However, research does not show that they offer an advantage when used routinely.

Some doctors or midwives see the risks in some of these practices and only use them when they offer a clear benefit. For example, assisted vaginal birth can help a baby who needs to be born quickly, or to avoid a C-section. To avoid the use of unnecessary childbirth practices, choose your care provider and birth setting carefully, asking about the use of these practices at the start. Go to the Research and Evidence section to read more about the pros and cons of the practices listed above.

Does the type of birth I have – vaginal or cesarean – impact whether I have incontinence later in life?

Researchers have investigated whether vaginal versus cesarean birth affects a woman’s likelihood of incontinence after birth. As the Research and Evidence page details, the best current evidence finds no difference in bowel incontinence (unintended loss of either stool or gas). However, a year or more after birth, in comparison with women with cesarean birth, about three percent more women with vaginal births experienced urge urinary incontinence and about eight percent more experienced stress urinary incontinence. Unfortunately, we don’t have the research to clarify whether the extra risk is due to vaginal birth itself or to practices that often go with vaginal birth that increase risk of harm and could be avoided for many women.

Older women experience high rates of incontinence, but this appears to be due to other factors like being overweight; smoking; having a hysterectomy (surgery to remove the uterus); having repeated urinary tract infections; and having certain diseases like diabetes, arthritis or Alzheimer’s. Women who have never been pregnant have high rates of urinary incontinence when they get older.

Should I plan a C-section (elective C-section) to prevent incontinence?

It’s important to know that C-sections have their own risks, some quite serious, in the shorter and longer terms for women, babies and babies in future pregnancies. To protect your pelvic floor, it would be wise to focus on having a vaginal birth without the concerning practices listed above. It would also be wise to avoid smoking, excess weight gain and other risk factors for incontinence (and other health problems). And a program of pelvic floor exercises (kegels) in pregnancy can help prevent incontinence problems. These exercises can also help treat those that might arise.

During pregnancy, how can I lower my risk for pelvic floor problems?

• Talk with your doctor or midwife about avoiding the use of the following interventions. These can increase your risk for pelvic floor disorders.
• Episiotomy (cutting the vaginal opening to enlarge it for birth).
• Pushing while lying on your back, with or without stirrups (versus being on your hands and knees), for women without epidurals (position does not seem to matter for women with epidurals).
• Pushing directed by a care provider, versus mother-directed pushing when you push at your own pace and strength, based on what feels natural (there are signs that pushing coached by the hospital staff can be harmful for women without epidurals, but more research is needed to understand this).
• Having a caregiver press on your abdomen (fundal pressure) to help get the baby out.
• Vacuum extraction or forceps delivery.



Tell your provider that unless there is a really good medical reason to use these practices, you don’t want to. If you don’t know who will be at your birth, ask your provider how you can be sure that your wishes will be respected. If the provider is not willing to work with you to achieve this goal, consider looking for others who will work with you on this (read Choosing a Care Provider for more information).

• Arrange for a birth doula or someone else who can provide continuous labor support. Doulas and other trained labor support specialists have practical knowledge about how to help labor progress smoothly and get labor on track when it isn’t going smoothly. Women who receive continuous supportive care in labor from a trained or experienced woman who is not a nurse, midwife or doctor are less likely to have an epidural or other pain medications, an assisted delivery or a C-section, and less likely to feel dissatisfied with their birth experience.Hodnett, E.D., Gates, S., Hofmeyr, G.J., & Sakala, C. (2013). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 7 (CD003766).
• Establish a regular pelvic floor muscle exercise program. A systematic review found that in pregnant women who did not experience incontinence, doing “kegel” exercises regularly in pregnancy reduced the likelihood of postpartum urinary incontinence compared with women who did not do these exercises. In women who experienced urinary incontinence (leaking) after birth, those who did pelvic floor muscle exercises were less likely to experience incontinence about a year after birth than those who did not do the exercises.Boyle, R., Hay-Smith, E.J., Cody, J.D., & Mørkved, S. (2014). Pelvic floor muscle training for prevention and treatment of urinary and fecal incontinence in antenatal and postnatal women: a short version Cochrane review. Neurourology and Urodynamics, 33(3):269-76.
• Consider establishing a perineal massage program in the final weeks of pregnancy. A systematic review has found that perineal massage, by a woman or her partner, once or more per week near the end of pregnancy, reduces perineal trauma, use of episiotomy and pain.Beckmann, M.M. & Stock, O.M. (2013). Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews, 4(CD005123);Lemos, A., de Souza, A.I., Ferreira, A.L., Figueiroa, J.N., & Cabral-Filho, J.E. (2008). Do perineal exercises during pregnancy prevent the development of urinary incontinence? A systematic review. International Urogynecology Journal, 15(10), 875-80;Mørkved, S. & Bø, K. (2014). Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. British Journal of Sports Medicine, 48(4), 299-310.

When giving birth, how can I reduce my risk for pelvic floor problems?

• Avoid an epidural. Epidural analgesia increases the likelihood of having an assisted birth (with vacuum extraction or forceps), which often also involves an episiotomy, and thus a tear into the anal muscle. Read more about epidural in the Labor Pain section of the website. Having a doula or someone else who can provide continuous labor support can also help you avoid an epidural.
• Avoid continuous electronic fetal monitoring. If you do not need special monitoring, ask for periodic (intermittent) monitoring, which can be done with a handheld Doppler, a special fetal stethoscope or the electric monitor.
• Allow your own instincts and your body’s pushing reflexes to guide pushing. When women follow their own inner sensations, they often don’t begin pushing until sometime after the opening of the uterus (cervix) is fully stretched (dilated). When they do bear down, pushes tend to last only a few seconds, in contrast to more prolonged and stressful staff-directed pushing to hurry the birth along. With mother-directed pushing, women are less likely to be injured or need stitches. Pushing in this manner allows the vaginal tissues to gently stretch around the baby’s head and may also avoid overstretching pelvic floor ligaments and muscles. (Many women with epidurals are unable to push in this way because they are numbed.)

How can I reduce my chance of having a vacuum extraction or forceps delivery (assisted vaginal birth)?

Research suggests you should:

• Arrange for a birth doula or an experienced friend or relative to provide continuous labor support. Women who have this kind of support when giving birth are much less likely to have an assisted vaginal birth than women without it. This kind of care can help you avoid the need for an epidural, help a labor progress smoothly, and get it back on track when it doesn’t.Hodnett, E.D., Gates, S., Hofmeyr, G.J., & Sakala, C. (2013). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 7 (CD003766).
• Avoid continuous electronic fetal monitoring (EFM) whenever possible. Women who have continuous EFM to keep track of the baby’s heart rate during labor are more likely to have vacuum extraction or forceps deliveries, and their babies are not born in better condition than those of women whose babies are monitored at regular intervals using a handheld device such as a Doppler or a specialized stethoscope. (Continuous EFM is needed to monitor side effects of some interventions, like Pitocin, to start or strengthen contractions or epidural analgesia; it is also needed when women in labor have a uterine scar from a previous C-section.)
• Push in an upright position. Avoid lying on your back (supine position) or on your back with legs in stirrups (lithotomy position). Some hospital beds can be adjusted to help you get comfortable in an upright or side position. A doula can help support you in these positions. You can also get help from the nursing staff or your partner. (At this time, the best evidence finds that pushing position only makes a difference for women who do not have epidurals.)

After the baby is born, how can I avoid pelvic floor problems?

You should continue your kegel exercises to strengthen your pelvic floor muscles and help resolve any problems with leaking urine (urinary incontinence).Boyle, R., Hay-Smith, E.J., Cody, J.D., & Mørkved, S. (2014). Pelvic floor muscle training for prevention and treatment of urinary and fecal incontinence in antenatal and postnatal women: a short version Cochrane review. Neurourology and Urodynamics, 33(3):269-76;Mørkved, S. & Bø, K. (2014). Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. British Journal of Sports Medicine, 48(4), 299-310. (The role of pelvic floor exercise in preventing and resolving bowel incontinence is unclear.) More is better when it comes to doing kegels. Substituting or adding other techniques such as using vaginal cones (inserting weighted cones into the vagina and holding them against gravity) or electrical stimulation (inserting a probe in the vagina or anus that passes a low current to the muscles around the bladder, stimulating them to contract) does not appear to offer any benefit over a program of kegel exercises.

 

Throughout life, how can I avoid pelvic floor problems?

• Maintain a healthy body weight. Losing excess pounds can reduce symptoms and your chance of developing diabetes, which also may be associated with leaking urine (urinary incontinence).
• Avoid smoking. If you cannot quit completely, limit the number of cigarettes per day to decrease your chance of urinary incontinence. This can reduce coughing, which may lead to improvements.
• Keep doing your kegel exercises. An intensive program of pelvic floor exercises can both prevent and treat urinary incontinence.
• Avoid hormone replacement therapy (HRT). Higher-quality studies have found that use of hormone replacement therapy is associated with urinary incontinence.
• Minimize repeated urinary tract infection and irritation. These are associated with urinary incontinence. Treatment can improve symptoms.
• Avoid having a hysterectomy, if possible. Surgical removal of the uterus appears to increase your likelihood of having urinary incontinence. There are less invasive ways to treat many problems that can lead to hysterectomy.