Incontinence and Prolapse After Birth

Pregnancy and childbirth bring a lot of joy – but unfortunately, they can also damage your pelvic floor. In fact, having a baby is a major risk factor for incontinence and prolapse.

The chance of pelvic floor problems is higher after a vaginal birth. However, having a Caesarean section doesn’t prevent incontinence and prolapse completely. Simply being pregnant can cause damage.

Pelvic floor problems are a whole specialized area of gynaecology, so we won’t be able to cover everything here. However, we’ll try to give you a brief overview with a particular focus on the links to pregnancy and birth.

Photo by Ignacio Campo on Unsplash

What is my pelvic floor?

Your pelvic floor is like a hammock of muscles and ligaments. It runs from your pubic bone at the front to your tailbone (coccyx). It supports your bowels, bladder and uterus. The openings of your bowel, bladder and uterus pass through the pelvic floor to reach the outside.

What happens if my pelvic floor is damaged?

The pelvic floor muscles help to control when you pass urine, faeces or wind. If your pelvic floor is damaged, you may lose control of your bowels or bladder (incontinence).

Urinary incontinence is the most common problem, especially “stress” incontinence (leaking after coughing, sneezing or physical activity). Bowel incontinence (leaking wind or faeces) is less common.

The pelvic floor also holds your bowels, bladder and uterus in the right position. If your pelvic floor is damaged, these organs can bulge into the vagina or even through the opening of the vagina. This is called a prolapse. You feel it as a heaviness or a lump.

How do pregnancy and childbirth damage my pelvic floor?

During pregnancy, a combination of hormones and pressure from the growing baby stretches your pelvic floor. If it stretches too far, the pelvic floor won’t work properly.

When you give birth, all the tissues are stretched even further and can tear as baby is born. The pressure of your baby’s head can also “squash” the nerves in your pelvis, leading to muscle weakness or a reduced sense of when you need to go to the toilet.

How likely am I to experience incontinence and prolapse?

It’s very common to have bowel or bladder symptoms in the first 3 months after giving birth. One big study estimated that 31% of women who give birth vaginally and 15% of women who have a caesarean will have at least one episode of urinary incontinence in the first 3 months.1 It’s also very common for women to initially feel prolapse-type symptoms of vaginal bulging or heaviness.

However, this is partly because your body is still recovering. Even a straightforward birth is a major physical event. Your body will do lots of healing in the first 3 months. Many women find that their initial symptoms significantly improve or disappear over this period of time.

It’s harder to be sure about the chance of long-term incontinence and prolapse, because lots of studies have looked at this question in slightly different ways and come up with different numbers.

However the evidence clearly shows that having a baby, and the way you give birth, both affect your chance of pelvic floor problems in later life.

For example, one study looked at how many women aged up to 65 years experienced moderate or severe urinary incontinence. It affected 3.7% of women who had never had a baby; 6.2% of women who only had caesarean births; and 8.7% of women who had a vaginal birth.2

The chance of long-term symptoms increases with:

  • Needing a forceps birth (in a Norwegian study, forceps increased the risk of urinary incontinence by 5% compared to spontaneous vaginal birth).3
  • A large baby (birthweight over 4kg makes you 1.5 times more likely to have incontinence)4
  • Long labour, especially a long pushing stage
  • Perineal tears, especially 3rd or 4th degree tears
  • Having bowel or bladder symptoms before the birth
  • Having 2 or more children

What other things increase my risk of incontinence and prolapse?

  • Getting older, especially after menopause
  • Genetics (ask your mother and grandmother if they have problems)
  • Higher BMI
  • Smoking
  • Chronic coughing
  • Persistent heavy lifting

Can I just have a Caesarean?

According to the Continence Foundation of Australia, a planned caesarean reduces your chance of severe incontinence from 10% to 5% if it is your first baby; however, after your 3rd caesarean you may be as likely to have urinary incontinence as a woman who had 3 vaginal births.5

People also ask why obstetricians still use forceps to deliver babies, given the higher chance of pelvic floor problems. It’s important to realize that depending on the circumstances, forceps can be the safest option at the point of delivery. For example, once your cervix is fully dilated and the head has moved down low into the vagina, a caesarean can be difficult and carry additional risks for you, the baby and future pregnancies. It also takes time to move a patient from Birth Suite to an operating theatre, so in time-critical emergencies, like severe fetal distress, a forceps delivery may be faster and safer for the baby. Vacuum and forceps aren’t totally interchangeable either. So, banning forceps because of the risk of pelvic floor damage could leave women and babies open to other serious complications. It is a balancing act.

What can I do to protect my pelvic floor?

  • Start Pelvic Floor Exercises during pregnancy
  • Talk to your obstetrician about delivery options and what can happen in different scenarios. There is no right answer here, it’s more about having the information and being prepared.
  • See a Women’s Health Physiotherapist starting around 6-12 weeks after birth. A WH physio will help you re-train your pelvic floor after childbirth.
  • If you have ongoing bothersome symptoms after birth, talk to your obstetrician or GP about further care. There are treatments available to help improve your symptoms and quality of life.

As always, this information is intended for general educational purposes only. It is not medical advice. Please discuss any medical issues with your own doctor. Read our full medical disclaimer here.

References

  1. Thom DH, Rortveit G. Prevalence of postpartum urinary incontinence: a systematic review. Acta Obstetricia et Gynecologica Scandinavica. 2010; 89: 1511-1522.  https://doi.org/10.3109/00016349.2010.526188
  2. Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S. Urinary Incontinence after Vaginal Delivery or Cesarean Section. March 6 2003. NEJM 2003; 348:900-907
  3. Tahinten  RM, Cartwright R, Vernooij RWM, Rortveit G, Hunskaar S, Guyatt GH, Tikkinen KAO.  Long-term risks of stress and urgency urinary incontinence after different vaginal delivery modes. Am J Obstet Gynecol. 2019 Feb; 220(2):181.e1-181.e8. doi: 10.1016/j.ajog.2018.10.034. Epub 2018 Nov 1.
  4. Wesnes SL, Seim E. Birthweight and urinary incontinence after childbirth: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol X. 2020 Oct; 8: 100115. Published online 2020 Sep 4. doi: 10.1016/j.eurox.2020.100115
  5. Continence Foundation of Australia. https://www.continence.org.au/incontinence/who-it-affects/women/pregnancy-and-childbirth. Accessed 19 September 2022.