By Natalie Christopherson
As a pregnant woman and pelvic floor physical therapist, I am surrounded by stories, advice, and opinions about the right way to give birth. Most of us know that pregnancy and childbirth often result in trauma to the pelvic floor and perineum, which can lead to incontinence, pelvic organ prolapse, and painful sex, among other things. In this post I hope to shed some light on how some common birth interventions affect the risk of pelvic floor trauma and dysfunction, so that other pregnant women can possibly lower their risk of complications. While we may not have complete control over the interventions used during delivery, and rely on our doctor or midwife to tell us what the best option is, if we know beforehand what the risks are, we can make informed choices and be active participants in our care.
The research on what increases a pregnant woman’s risk of perineal and pelvic floor trauma points to various factors that cannot be changed, such as primiparity (women delivering their first baby) and heavier babies.1,2 However, certain risk factors can be controlled, such as operative vaginal delivery (with forceps for example), the use of episiotomy, and a longer second stage of labor, which can be related to the use epidural anesthesia.2,3,4 The way we choose to prepare ourselves for birth, the caregivers we choose to assist us, and how we communicate with them can help to mitigate some of these risk factors.
Operative vaginal delivery refers to the use of an instrument to help the fetus exit the vagina. This is most commonly done with forceps, which are kind of like a pair of salad tongs that pinch the babies head, or with a vacuum extractor, which has a cup that suctions onto the babies head to help pull it out. These interventions may be necessary if labor is not progressing, mom’s pushing is not effective, or the baby is in distress and needs an expedited delivery. There have been multiple studies to show that operative vaginal delivery in general, and the use of forceps in particular, increases the risk of perineal trauma and pelvic floor disorders.1,2,3,5,6 The American Journal of Obstetrics and Gynecology points out in a review that “operative intervention is not warranted just because a set number of hours have elapsed in the second stage,” 7 meaning that as long as baby and mom appear healthy and are adequately coping, just because labor is taking a long time doesn’t necessarily mean that your doctor should reach for the forceps or the vacuum extractor to help. They suggest that the second stage of labor can continue without these interventions for a minimum of two to three hours in women with epidurals, and one to two hours in women without them (the shorter time frame for moms who have given birth previously and longer time frame for first time moms).7 As long as mom and baby are doing OK, you or your birth support person may ask your provider if these interventions are truly necessary, or if they can wait to see if delivery will be successful without them. There will be instances where these interventions are needed to ensure the health of mom or baby, but if that’s not the case then you may save your perineum some trauma by avoiding them.
Another common birth intervention is the episiotomy, where a surgical incision is made in the perineum to widen the vaginal opening. An episiotomy may be required if baby is very large, is in an abnormal position, or needs to be delivered very quickly. Though episiotomies used to be routine, the American College of Obstetricians and Gynecologists (ACOG) recommends against the routine use of episiotomy, stating that this practice provides no beneficial effect to the function of the pelvic floor when compared with using it only in select cases.8 According to the American Journal of Obstetrics and Gynecology, routine use of episiotomy is associated with potential healing complications and later pain with intercourse,7 and avoiding episiotomy has been shown to increase perineal integrity.3,5 However other research has found that episiotomy was not associated with pelvic floor disorders 5-10 years after delivery.6 Though research is mixed, the consensus seems to be that unless it is completely necessary, episiotomy should be avoided.9 According to ACOG, 53-79% of women who delivery vaginally will experience some type of perineal tearing, but that most of the time this does not result in poor functional outcomes.8 Episiotomies have not been shown to speed healing or prevent spontaneous perineal tearing,10 so unless the surgical incision is necessary for some other reason, a spontaneous perineal tear may be preferable and may be associated with fewer complications. Talking to your healthcare provider prior to delivery to ensure that episiotomies are not standard procedure in your hospital and only performed when necessary may prevent you from undergoing unnecessary perineal trauma.
Epidural anesthesia is a very common pain management technique used during labor and delivery, with more than 50% of women who give birth in US hospitals receiving an epidural.11 A medicine that decreases your sensation of pain is injected into the area around the spinal cord, affecting the lower segments of the spinal nerves, so that you remain awake during delivery but don’t feel as much pain. Because the medications affect the nerve impulses that travel from the spine to the entire lower half of the body, depending on the type of epidural used, it may prevent mom from being able to use her legs effectively. The inability to move, walk, or change position can cause labor to slow or stop, resulting in increased labor times. Research suggests that having an epidural may result in a longer second stage of labor and higher rates of episiotomy,4 which have in turn been associated with increased risk of pelvic floor trauma.3 A study from Obstetrics and Gynecology found that about 16.1% of women who had an epidural suffered third or fourth degree perineal lacerations, compared to 9.7% of women who did not.12 This study concluded that this risk increase resulted from the increased use of operative vaginal delivery and episiotomy in the group that had the epidural compared to those who did not.12 An epidural can decrease the laboring woman’s ability to feel and therefore assist with contractions, which means that help of forceps or a vacuum extractor is more often needed in these women because pushing is more difficult. So it may not be the epidural itself that increases the risk of perineal trauma, but the resulting interventions. That being said, I have heard from many moms who had epidural anesthesia and were entirely happy with their birth experience and outcome. Furthermore, if the laboring woman is in distress or having a protracted labor, an epidural may very well be needed to prevent complications. To read more about the pros and cons of epidurals, visit the American Pregnancy Association’s website here.
One thing to note is that most of the available research is conducted on women who had uncomplicated pregnancies, normal presentation of the fetus at birth, and who entered labor spontaneously when they were full term. Therefore, these particular studies may not apply to women who are delivering babies in an abnormal position, who go into labor early, or have other complications with pregnancy and labor.
Assuming a normal pregnancy and delivery, what can we moms do to decrease risk of pelvic floor and perineal trauma? There are various things that can help in the delivery room to prevent perineal tears or the need for an episiotomy, such as warm compresses to the perineum, perineal massage during the second stage of labor, upright birth positions (see Malinda’s blog on this here), and using maternal pushing instead of coached pushing (see Malinda’s other blog on this here). If you want to avoid having an epidural, there are a lot of ways you can prepare to use alternative pain coping strategies such as breathing, relaxation exercises, TENS, positioning, massage, or birthing tubs. Pregnant women can also prepare physically prior to delivery to help decrease the risk of perineal trauma during childbirth by doing exercise, stretches, labor rehearsal, or perineal massage (for more information see Stephanie’s blog about this here).
If you do find yourself needing an episiotomy or sustaining a perineal tear, just know that they do heal. If you are having trouble with urinary incontinence, pelvic organ prolapse, painful sex, or any other pelvic floor complaints after childbirth, come see us at PHRC – pelvic floor physical therapy can help!
- Dahlen HG, Ryan M, Homer CS, Cooke M. An Australian prospective cohort study of risk factors for severe perineal trauma during childbirth. Midwifery. 2007;23(2):196-203.
- Smith LA, Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy Childbirth. 2013;13(1): 59.
- Handa VL, Harris TA, Ostergard DR. Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ prolapse. Obstet Gynecol. 1996;88(3):470-8.
- Bodner-Adler B, Bodner K, Kimberger O, et al. The effect of epidural analgesia on obstetric lacerations and neonatal outcome during spontaneous vaginal delivery. Arch Gynecol Obstet. 2003;267(3):130-3.
- Eason E, Labrecque M, Wells G, Feldman P. Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol. 2000;95(3):464-71.
- Handa V, Blomquist J, McDermott KC, Friedman S, Muñoz A. Pelvic Floor Disorders After Childbirth: Effect of Episiotomy, Perineal Laceration, and Operative Birth. Obstet Gynecol. 2012; 119(2 Pt 1): 233–239.
- Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet Gynecol. 2008;199(5):445-54. doi: 10.1016/j.ajog.2008.06.093.
- Bozkurt M, Yumru AE, Şahin L. Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor. Taiwan J Obstet Gynecol. 2014;53(4):452-8.
- Albers LL, Anderson D, Cragin L, et al. Factors related to perineal trauma in childbirth. J Nurse Midwifery. 1996;41(4):269-76.
- Robinson JN, Norwitz ER, Cohen AP, McElrath TF, Lieberman ES. Epidural analgesia and third- or fourth-degree lacerations in nulliparas. Obstet Gynecol. 1999;94(2):259-62.