Best Evidence: Pelvic Floor 

KEY MESSAGES ABOUT PELVIC FLOOR DYSFUNCTION AND GIVING BIRTH

• Episiotomy: The routine or frequent use of episiotomy (cutting the vaginal opening to enlarge it for birth) has no advantages and many disadvantages. These include painful vaginal area, problems with episiotomy healing, and painful sexual intercourse. Midline episiotomy (the cut goes straight back) can lead to tears into the anal muscle.
• Anal muscle injury: Women with anal muscle injuries are more likely to develop leaking gas, a sence of urgency about elimination, or more rarely leaking feces (bowel incontinence).
• Assisted vaginal birth: Compared with women giving birth by their own efforts (spontaneous vaginal birth), women who have vacuum extraction or forceps deliveries (assisted vaginal birth) are more likely to experience anal muscle tears, infection, pain, bowel problems, urinary incontinence (with forceps only), bowel incontinence, and sexual problems.
• Vacuum extraction vs. forceps: Vacuum extraction is less likely to harm the pelvic floor than forceps delivery.
• Continuous electronic fetal monitoring to keep track of the fetal heart rate leads to more assisted deliveries without any improvement in the number of babies born in poor condition than intermittent monitoring.
• Epidural analgesia increases risk for more assisted deliveries and tears into the anal muscle.
• Kegel exercises: Doing pelvic floor exercises (kegel exercises) regularly in pregnancy and after birth can help prevent, improve or cure urinary incontinence. An intensive program is better than a less intensive program.

• midline episiotomy
• mediolateral episiotomy
• assisted vaginal birth (vacuum extraction or forceps delivery)
• continuous electronic fetal monitoring
• epidural analgesia
• fundal pressure
• pushing style
• kegel exercises
• perineal massage

What are some concerns about effects of anal muscle tears?

• delayed healing: women who have an anal muscle injury are more likely to have a wound that hasn't closed or an infection 1 to 2 weeks after the birth compared with women without anal muscle injury.
  Added likelihood for a woman with anal muscle injury: VERY HIGH for delayed healing
• bowel incontinence: anal muscle injury can lead to leaking gas, a sense of urgency about elimination, or more rarely leaking feces (bowel incontinence).
  Added likelihood for bowel incontinence with anal muscle injury cannot be determined from studies examined

What are some concerns about effects of midline episiotomy?

• tear that extends into or through the anal muscle:
  Added likelihood for a woman who has a midline episiotomy compared with no episiotomy: VERY HIGH for a tear extending into the anal muscle
• delayed healing: women who have a midline episiotomy are more likely to have a wound that hasn't closed or an infection 1 to 2 weeks after the birth compared with women with no episiotomy.
  Added likelihood for a woman with midline episiotomy: HIGH for delayed healing
• vaginal and perineal pain: as the depth of injury to the perineum increases from no injury at all (intact perineum) to spontaneous tear to episiotomy to tear into the anal muscle, the likelihood of experiencing severe pain 3 months after the birth or having pain most or all of the time also increases.
  Added likelihood for severe or long-lasting pain in a woman who has a midline episiotomy cannot be determined from studies examined
• pain during first sexual intercourse: as the depth of injury to the perineum increases from no injury at all (intact perineum) to spontaneous tear to episiotomy to tear into the anal muscle, the likelihood of experiencing pain when resuming sexual intercourse also increases. Women with no injury to the perineum are also likely to resume sexual relations sooner and to say that any discomfort they experienced during intercourse was mild.
  Added likelihood for pain when resuming sexual intercourse in a woman who has a midline episiotomy cannot be determined from studies examined

What are some concerns about effects of mediolateral episiotomy?

• vaginal and perineal pain: women who have a mediolateral episiotomy are more likely to experience pain in the first few days after birth than women with a spontaneous tear (women who have no tear are much less likely to report significant pain on the first day after birth compared with women who have had a mediolateral episiotomy; up to half may report no pain at all).
  Added likelihood for a woman who has a mediolateral episiotomy compared with a woman who has a spontaneous tear: HIGH for needing pain medication in the first few days after birth
• pain during intercourse: women who have a mediolateral episiotomy are more likely to experience pain during intercourse in the first 2 to 3 months after birth than women who have a spontaneous tear.
  Added likelihood for pain during sexual intercourse in a woman who has a mediolateral episiotomy compared with a woman who has a spontaneous tear cannot be determined from studies examined
• poor early perineal healing: women who have a mediolateral episiotomy are more likely to have redness, swelling, and a wound that has not closed 5 days after birth than women who have a spontaneous tear.
  Added likelihood for a woman who has a mediolateral episiotomy compared with a woman who has a spontaneous tear: VERY HIGH for poor early perineal healing
• infection: women who have a mediolateral episiotomy are more likely to develop an infection than women with a spontaneous tear.
  Added likelihood for a woman who has a mediolateral episiotomy compared with a woman who has a spontaneous tear: HIGH for developing an infection
• abnormal long-term healing: women who have a mediolateral episiotomy are more likely to have scarring, healing with a puckered appearance, or pain with pressure on the scar at 2 to 3 months compared with women who have a spontaneous tear.
  Added likelihood for a woman who has a mediolateral episiotomy compared with a woman who has a spontaneous tear: HIGH for abnormal long-term healing

What are some concerns about the effects of vacuum extraction or forceps on the pelvic floor?

• tears in the perineum (the tissue between the back of the vagina and the anus) that extend into or through the anal muscle: a woman who has an assisted delivery (and especially a forceps delivery) is at increased risk for tears from the opening of the vagina back into the anal muscle, in comparison with a woman with spontaneous vaginal birth (research suggests that almost all of these serious tears can be avoided if women with assisted delivery do not also have an episiotomy).
  Added likelihood for a woman who has vacuum extraction: VERY HIGH to HIGH for a tear extending into the anal muscle
  Added likelihood for a woman who has forceps: VERY HIGH for a tear extending into the anal muscle
• infection: a woman who has had assisted delivery appears to be at increased risk for infection in her uterus and iif she has had an episiotomy or a tear in her vaginal area for infection of that wound, in comparison with a woman with spontaneous vaginal birth.
  Added likelihood for a woman who has an assisted vaginal birth: VERY HIGH to HIGH for infection of the perineum; HIGH for infection within the uterus
• vaginal and perineal pain: a woman who has had an assisted delivery is at increased risk for vaginal and perineal pain in the weeks and months after birth, in comparison with a woman with spontaneous vaginal birth.
  Added likelihood for a woman who has an assisted vaginal birth: VERY HIGH for a painful vaginal area
• bowel problems: a woman who has had an assisted delivery is at increased risk for bowel problems of any sort in the weeks and months after birth, in comparison with a woman with spontaneous vaginal birth.
  Added likelihood for a woman who has an assisted vaginal birth: VERY HIGH to HIGH for bowel problems
• urinary incontinence: a woman who has had a forceps delivery may be at increased risk for leaking urine (urinary incontinence) in the weeks and months after birth, in comparison with a woman with spontaneous vaginal birth (vacuum extraction does not appear to increase this risk).
  Added likelihood for a woman who has forceps cannot be determined in light of mixed results among studies
• bowel incontinence: a woman who has had a forceps delivery is at increased risk for leaking gas or feces (bowel incontinence) in the weeks and months after birth, in comparison with a woman with spontaneous vaginal birth (vacuum extraction may or may not increase the risk of having this complication).
  Added likelihood for a woman who has forceps: VERY HIGH to HIGH for some leaking gas or stool in the period after birth
  Added likelihood for a woman who has vacuum extraction cannot be determined in light of mixed results among studies
• hemorrhoids: a woman who has had an assisted delivery is at increased risk for hemorrhoids in the weeks and months after birth, in comparison with a woman with spontaneous vaginal birth.
  Added likelihood for a woman who has an assisted vaginal birth: VERY HIGH to HIGH for hemorrhoids
• sexual problems: a woman who has had assisted vaginal birth is at increased risk for sexual problems (such as pain with intercourse) in the weeks and months after birth, in comparison with a woman with spontaneous vaginal birth.
  Added likelihood for a woman who has an assisted vaginal birth: VERY HIGH for sexual problems in the weeks and months after birth
• poor overall functioning: a woman who has had an assisted delivery is at risk for poorer physical and social functioning in the early weeks after birth than a woman with spontaneous vaginal birth.
  Added likelihood for poor overall functioning cannot be determined from studies examined

What are some concerns about effects of continuous electronic fetal monitoring?

• assisted vaginal birth:
  Added likelihood for assisted vaginal birth cannot be determined from studies examined

What are some concerns about effects of epidural analgesia?

• assisted vaginal birth:
  Added likelihood for assisted vaginal birth cannot be determined from studies examined
• tears in the tissue between the vagina and the anus (perineum) that extend into or through the anal muscle:
  Added likelihood for assisted vaginal birth cannot be determined from studies examined

What is a concern about effects of fundal pressure (a caregiver pressing on the woman's abdomen to help move the baby out)?

• tears in the tissue between the vagina and the anus (perineum) that extend into or through the anal muscle:
  Added likelihood for a woman who has fundal pressure: VERY HIGH for a tear extending into the anal muscle

What is a concern about effects of forceful sustained caregiver-directed pushing (versus pushing guided by a woman's own "urge to push" reflex)?

• tears in the tissue between the vagina and the anus (perineum) that require stitching or episiotomy:
  Added likelihood for a woman using caregiver-directed pushing: cannot be determined from studies examined

What are some concerns about pushing your baby out while lying on your back (versus pushing in various upright or side-lying positions)?

• episiotomy:
  Added likelihood for a woman pushing on her back: HIGH for having an episiotomy
• assisted vaginal birth:
  Added likelihood for a woman pushing on her back: HIGH for giving birth with vacuum extraction or forceps

What is the benefit of pelvic floor exercises (kegel exercises) for preventing or relieving leaking urine when the pelvic floor is stressed by coughing, sneezing, laughing, or lifting heavy objects (urinary stress incontinence)?

• prevent, improve or cure urinary incontinence after birth if done during pregnancy: Incontinence measured as early as 3 months and as late as 4 years after birth.
  Added likelihood for a woman who does kegel exercises regularly during pregnancy: VERY HIGH for being continent by 3 months after birth
• prevent, improve or cure urinary incontinence if done after birth
  Added likelihood for an incontinent woman who does kegel exercises regularly after birth: HIGH for improvement or cure

Is using weighted vaginal cones or electrical stimulation better than kegel exercises for improving or curing urinary stress incontinence?

Does combining kegel exercises with vaginal cones, electrical stimulation, or biofeedback do better at improving or curing urinary stress incontinence than a program of kegel exercises alone?

What is the benefit of a routine of perineal massage in the final weeks of pregnancy?

• prevent trauma to the perineum, defined as episiotomy and spontaneous tears combined, and promote birth with an intact perineum in first-time mothers (evidence of effectiveness in subsequent pregnancies unclear at this time) Added likelihood for a first-time mother: VERY HIGH to HIGH for avoiding perineal trauma and giving birth with an intact perineum.