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Pelvic Floor Q&A

Updated: Jan 12, 2021

What birth practices can affect the pelvic floor?

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.

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.

  • 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.

  • 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.

  • 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.

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). (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.

This information was written and published by Childbirth Connection- a program of the National Parternship for Women & Families. This content can also be found here:

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