The Reality of Pelvic Floor Damage

by Connie Banack

In current media and recent journal articles vaginal birth is portrayed as the cause of all problems when it comes to pelvic floor damage, both immediate and long-term. To avoid such trauma, many claim loudly and often the benefits of elective cesarean, citing it as the way to a virginal vagina, better sexual experiences, a sound pelvic floor, and avoiding incontinence. Let us look at the literature and womenísí experiences to find the reality of these beliefs.

The pelvic floor is a network of muscles, ligaments, and tissues that act like a hammock to support the organs of the pelvis: the uterus, bladder, and rectum. If the muscles become weak or the ligaments or tissues are stretched or damaged, the pelvic organs may drop down and protrude into the wall of the vagina. The result is inferior sexual enjoyment, incontinence and worse.

Common knowledge is that pelvic floor disorders usually result from a combination of factors. Being pregnant and having a vaginal delivery may weaken or stretch some of the supporting structures in the pelvis. Pelvic floor disorders are more common among women who have had several vaginal deliveries, and the risk may increase with each delivery. The delivery itself may damage nerves, leading to muscle weakness. Finally the commonly held belief is that delivery by cesarean section will reduce the risk of developing a pelvic floor disorder.

What is not told, however, is that most pelvic floor relaxation is caused during pregnancy from the weight of the baby and a hormone called relaxin that softens the connective tissue of the pelvic structures in preparation for birth. Often avoidable interventions like forceps, vacuum extraction and episiotomy also greatly increase the risk of pelvic floor problems. Avoidable you ask? Absolutely. In obstetrics today, women are giving birth most often in a semi-seated position on an obstetrical birth bed, which is believed to be physiologically beneficial given its semblance of a supported squat. While beneficial for the attending physician, it impacts the mobility of the pelvis, as the sacrum and coccyx are immobilized by the back and bottom of the bed. Instead of the sacrum (the most flexible bone of the pelvic triangle) moving easily out of the way as the baby moves down through the pelvis and birth canal, the babyís descent is slowed or even arrested by its immobility. In addition, sitting on the coccyx during birth also restricts the pelvic outlet and can lead to dislocation of the coccyx.[i] In response to this lack of progress, obstetrical management dictates prolonged breath holding and pushing to move the baby past the sacrum. This puts additional stress on the pelvic floor as the reduced diameter of the pelvic outlet causes a two-fold effect. The fetal head to puts increased pressure on the anterior pelvic wall, the inside of the pubis symphysis, increasing the risk of a cystocele because of the downward pressure of the fetal head as it descends, pulling the neck of the bladder downward. Then, as the baby descends to the vaginal outlet, the fetal head puts great pressure on the anal sphincter as it compresses against the bed. This greatly increases the risk of hemorrhoids and rectoceles. When prolonged breath holding and pushing are not effective, the use of instruments to assist in birth are then turned to, all of which negatively impact the pelvic floor.[ii] Episiotomy, a cut made at the back of the vagina to enlarge the opening for birth, was a common intervention long believed by physicians to protect the vagina from trauma. Midwives and post-episiotomy mothers knew the truth to be the opposite and finally a study large obstetrical has concluded this.[iii]

A rectocele is a disorder in which the rectum drops down and protrudes into the back wall of the vagina. A rectocele can make having a bowel movement difficult and may cause a sensation of constipation. Some women need to place a finger in the vagina to have a bowel movement. A cystocele develops when the bladder drops down and protrudes into the front wall of the vagina. It results from weakening of the connective tissue and supporting structures around the bladder. This disorder may cause stress incontinence (passage of urine during coughing, laughing, or any other maneuver that suddenly increases pressure within the abdomen) or overflow incontinence (passage of urine when the bladder becomes too full). After urination, the bladder may not feel completely empty. Sometimes a urinary tract infection develops. Because the nerves to the bladder or urethra can be damaged, women who have these disorders may develop urge incontinence (an intense, irrepressible urge to urinate, resulting in passage of urine).

Now, let us look at the other side of the coin for a minute shall we? Cesarean section is touted as the great reducer of pelvic floor concerns and preserver of sexual satisfaction. If this is true, then how is it that many cesarean mothers have short-term urinary incontinence concerns? This has been explained away as the result of pregnancy hormones which will resolve within weeks of the babyís birth. However, in discussion with post-cesarean mothers, urinary incontinence can last months and even years post-birth. There are no long-term studies of the prophylactic benefits of cesarean section on pelvic floor health. Interestingly, recent studies have also shown that even Nuns have a moderate possibility of developing urinary incontinence.[iv]

Fecal incontinence and hemorrhoids are surely avoided with a surgical delivery, right? Wrong. Postoperative pain medications cause constipation which increases hemorrhoid risk. More importantly, the surgical risks of a cesarean include nicked colon, intestinal trauma and adhesions impact colon health by cutting off the blood supply or even obstructing the colon.[v] These are conveniently avoided in addressing the benefit of prophylactic cesarean section.

What isnít being discussed in the literature is the very real risk of adhesions and their effect on sexual pleasure. Several women I have spoken to post-cesarean have expressed their concern of discomfort during sex. In analyzing their concerns, the common thread found is of adhesions causing the uterus to tip back which in turn moves the cervix forward and towards the vaginal opening, reducing the size of the fornix. The combination of impact on the cervix and/or the back of the fornix during sex are explained as very uncomfortable, even painful, for these women. Some women even express a feeling something is hitting their sacrum. I have hypothesized this as the unpregnant uterine fundus in its posterior state actually impacting the inner sacrum or a stretched of adhesions causing that sensation.

This makes us ponder the importance of pelvic floor health in relation to all pregnancy outcomes. Yet obesity, chronic coughing (for example, due to a lung disorder or smoking), frequent straining during bowel movements, and heavy lifting can also contribute to pelvic floor disorders. Other causes include a hysterectomy, nerve disorders, injuries, and tumors. Some women are born with weak pelvic tissues. As women age, the supporting structures in the pelvis may weaken, making pelvic floor disorders more likely to develop.

Is there hope for women and their pelvic floors? Studies have shown there are. Kegels, pelvic floor exercises, are shown to improve both urinary and fecal incontinence.[vi] Kegels will also help reduce cystocele, rectocele and vaginal prolapse. To do these exercises, first locate the pubococcygeus muscles by sitting on the toilet while in urinating, stop and start the stream several times. Now the exercise is simply squeezing your PC muscles as hard as you can for a count of three to five seconds. Then let them relax. To begin with, see how many times you can do this before the muscles feel tired. Now figure out a suitable exercise routine just as you would if you were trying to tone and strengthen a different muscle group by going to the gym every other day. For example, suppose you start by being able to do only five strong squeezes; try doing three sets of five once or twice a day for a week, and then try increasing this to three sets of eight strong squeezes. Perform Kegel exercises as often as possible. Pick an activity you do often as a reminder such as when the phone rings or during TV commercials. If you work up to three sets of thirty or more strong squeezes, you are probably healthy enough for most purposes, and need only to maintain this level of fitness by doing these three sets four times a week (instead of once or twice a day).

What about increasing our knowledge about birth? Through the Pink Kit[vii] is an amazing resource for birthing women and their partners to learn about the pelvis, relaxation and movement to enhance birth. In knowing your specific pelvis, you can birth easier with less discomfort and greatly reduced pelvic floor trauma.

Additional options are Mayan Abdominal Massage and physiotherapy. Normally the uterus leans slightly over the bladder in the center of the pelvis, about one and a half inches above the pubic bone. It is held in this position by muscles, the vaginal wall and ligaments that attach it to the back, front, and sides of the pelvis. Uterine ligaments are made to stretch to accommodate a growing fetus inside and to move freely when the bladder or bowel is full. The ligaments and muscles can weaken and loosen, causing the uterus to fall downward, forward, backward or to either side. A uterus in any of these positions is called tilted or prolapsed. Modern medicine has little or nothing to offer women with this problem. Generally they are told, "your uterus is tipped, but that is normal and don't worry about it." Yet women have a laundry list of physical and emotional symptoms that can be addressed and prevented with these simple, noninvasive massage techniques.[viii] When done properly, external massage strengthens the ligaments and muscles that support the uterus and ovaries. Depending on the severity of the problem, it may take a few minutes or a few months for the uterus to slide back into place and stay there.

Physiotherapy treatment programs may include: pelvic muscle exercises (Kegel), biofeedback, electrical stimulation, pain reducing techniques, musculoskeletal treatment, trigger point therapy, core stabilization, internal perineal massage, bladder & bowel retraining and patterning, dietary modifications, postural education and relaxation techniques.

While the jury is still out on the assumed benefits of cesarean section, lets choose to avoid unnecessary major abdominal surgery and its risks to maternal health and turn instead to reducing the risks associated with pelvic floor trauma and support those important muscles through exercise and more, if needed.

About Connie

Connie is a certified childbirth doula, postpartum doula, and childbirth educator and an approved doula trainer through the Global Birth Institute. Connie has supported women during childbirth since 1997 and owns a Canadian-based doula agency, which provides perinatal services throughout central Alberta. 

Her volunteer time is devoted to the International Caesarean Awareness Network (ICAN) Inc as Education Director and as President of the Canadian Doula Association. She is studying homeopathy in her spare time, reads voraciously and loves to bike ride with her children around the community. Connie and her husband have four children, three of whom were born by cesarean section.


[i] Balaskas J, Active Birth, Harvard Common Press Boston, 1992, p 139
[ii] Maternity Center Association. What Every Pregnant Woman Needs ti Know About Cesarean Section. July 2004.
[iii] Hartmann K et al. Routine Episiotomy Harms and Offers No Benefits to Women. JAMA, May 4, 2005
[iv] Buchsbaum et al. Prevalence of Urinary Incontinence and Associated Risk Factors in a Cohort of Nuns Obstet Gynecol.2002; 100: 226-229.
[v] Maternity Center Association. What Every Pregnant Woman Needs to Know About Cesarean Section. July 2004.
[vi] Glazener CM, Herbison GP, Wilson PD, MacArthur C, Lang GD, Gee H, Grant AM. Conservative management of persistent postnatal urinary and faecal incontinence: randomised controlled trial. BMJ. 2001 Sep 15;323(7313):593-6.
[vii] Common Knowledge Trust. The Pink Kit. 2005.
[viii] Definition of Arvigo Techniques of Mayan Abdominal Massage,
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