The pelvic floor consists of muscles and ligaments that support the pelvic organs (bladder, uterus and bowel) as well as helping to maintain continence, which is preventing leakage of urine, wind or faeces. The muscles of the pelvic floor lie like a hammock from the pubic bone to the tail bone and out to the sit bones at the side.

It is well known that childbirth can affect the pelvic floor and its muscles and ligaments. This may lead to urinary or faecal (bowel) incontinence, pelvic organ prolapse and pelvic floor pain. In recent years there has been an increase in requests for caesarean sections when there is no medical indication for it. This in part has been due to women wanting to reduce any trauma to the pelvic floor therefore avoiding problems. But is having a caesarean section really that protective against damage to the pelvic floor?

Caesarean sections which are performed before the onset of labour (such as an elective caesarean) have shown to be protective of nerve damage to the pelvic floor although other studies have shown that pelvic floor problems may still arise. (It is has been suggested that the weakening and stretching of ligaments and muscles of the pelvic floor begins during pregnancy). Caesarean sections that are performed after a period of labouring have an increased risk of urinary incontinence compared to an elective caesarean.

How does this compare to vaginal deliveries? Studies show that the majority of childbirth related injuries that affect pelvic floor function occur with the first vaginal delivery. Factors that may increase the risk of damage to the pelvic floor are a high birth weight, prolonged second stage of labour (the pushing part) and difficult instrumental deliveries such as the use of forceps. Studies show that vaginal deliveries are related to an increased risk of pelvic floor problems compared to caesarean section deliveries. However less than half of women who deliver vaginally will be affected.

There is ongoing research investigating how the labouring and delivery of a baby vaginally can be more protective on the pelvic floor. For example; How to avoid maternal fatigue (mother becoming exhausted) which increases the use of instrument-assisted deliveries therefore increasing the risk of pelvic floor trauma? Studies have shown that the position of the mother when delivering their baby is also important. Delivering in an upright position or lying on the side, have shown to have benefits such as a shortened second stage of labour (therefore less time pushing), less instrument-assisted deliveries and less trauma to the pelvic floor.

There is increasing evidence that women who have stress incontinence (e.g. leaks with coughing or any exertion) during their pregnancy are more likely to have incontinence after delivery regardless of whether they gave birth vaginally or by caesarean section.

It is reasonable to conclude that having a caesarean section is not totally protective of the pelvic floor and should not be considered for this reason alone. It may be that certain women would benefit from a caesarean section due to past pelvic floor trauma or when there are non modifiable risks such as a large baby and a mothers’ small pelvic outlet.

WHAT CAN WOMEN DO TO ASSIST PELVIC FLOOR FUNCTION?

Exercising the pelvic floor muscles can assist in the management and prevention of incontinence and pelvic organ prolapse. Other factors that are beneficial, are maintaining a healthy weight and regular exercise such as walking, swimming, pilates and going to the gym.

To exercise the pelvic floor muscles, the correct technique needs to be learnt. Tightening the pelvic floor muscles should feel like you are squeezing and lifting up into your vagina. It may feel like what you do when you try to stop passing wind or urine.

Pelvic floor muscle exercise regimes do vary but the following programme uses current knowledge of exercise physiology to increase muscle strength and endurance (that is not tiring easily).

8-12 strong lifts - 3 times per day

Hold each lift 6-8 seconds followed immediately by 3-4 fast lifts

Rest 6 seconds

Do these 3-4 days per week for 5 months to attain ideal strength

Do these 2 days per week to maintain strength

After childbirth the pelvic floor muscles can be very weak and the ability to lift and hold these muscles is limited. It is recommended that if you are having problems exercising your pelvic floor muscles and/or have problems with incontinence or prolapse, that you see a Women’s Health Physiotherapist. You can access a list of physiotherapists who specialise in this area from the New Zealand Continence Association 0800 650 659

By Maree Frost, Womens’ Health Physiotherapist, Christchurch