Contribution of the second stage of labour to pelvic floor dysfunction: a prospective cohort comparison of nulliparous women

BJOG. 2014 Aug;121(9):1145-53; discussion 1154. doi: 10.1111/1471-0528.12571. Epub 2014 Feb 19.


Objective: Maternal expulsive efforts are thought to damage the pelvic floor. We aimed to compare pelvic floor function and anatomy between women who delivered vaginally (VB) versus those with caesarean delivery (CD) prior to the second stage of labour.

Design: Prospective cohort.

Setting: University Hospital Midwifery practice.

Population: Nulliparas.

Methods: Pregnant nulliparas were recruited during pregnancy and women who underwent CD prior to the 2nd stage of labour at birth were recruited immediately postpartum. Both groups were followed prospectively to 6 months postpartum.

Main outcome measures: POPQ, perineal ultrasound (U/S) and Paper Towel Test (PTT), an objective measure of stress incontinence; Incontinence Severity Index (ISI), Pelvic Floor Impact Questionnaire (PFIQ-7), Wexner Fecal Incontinence Scale (W) and Female Sexual Function Index (FSFI).

Results: 336/448 (75%) VB and 138/224 (62%) CD followed up. The VB group was younger (23.9 ± 4.9 versus 26.6 ± 6.1 years, P < 0.001) and less overweight/obese (38 versus 56%, P < 0.001); baseline functional measures were similar (all P > 0.05). At follow-up, urinary incontinence (UI) (55 versus 46% ISI > 0, P = 0.10), fecal incontinence (FI) (8 versus 13% FI on W, P = 0.12), sexual activity rates (88 versus 92%, P = 0.18) and PFIQ-seven scores were similar. Positive PTT tests (17 versus 6%, P = 0.002) and ≥ Stage 2 prolapse (22 versus 15%, P = 0.03) were higher with VB; differences were limited to points Aa and Ba. U/S findings were not different between groups. Stepwise multivariate analyses controlling for age, body mass index, and non-Hispanic White race for prolapse of points Aa and Ba did not alter conclusions (all P < 0.004).

Conclusions: VB resulted in prolapse changes and objective UI but not in increased self-report pelvic floor dysfunction at 6 months postpartum compared with women who delivered by CD prior to the second stage of labour. The second stage of labour had a modest effect on postpartum pelvic floor function.

Keywords: Caesarean section; incontinence; pregnancy; prolapse; vaginal birth.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Cesarean Section / adverse effects
  • Fecal Incontinence / etiology*
  • Female
  • Humans
  • Labor Stage, Second / physiology
  • New Mexico
  • Parity
  • Pelvic Floor / physiopathology*
  • Pelvic Floor Disorders / etiology*
  • Pregnancy
  • Prospective Studies
  • Risk Factors
  • Sexual Dysfunction, Physiological / etiology*
  • Surveys and Questionnaires
  • Urinary Incontinence / etiology*
  • Young Adult