Beyond the Incision: Understanding Pelvic Floor Issues After Cesarean Delivery

I once had a urogynocologist say that all women should have a cesarean to protect the pelvic floor. However, the research doesn’t support this. A 2003 study by Rortveit G et al showed rates of urinary incontinence in women were the same regardless of mode of delivery by the time they reach 50s in age. And a 2015 study by Kabaklan-Khasholian et al showed a correlation with cesarean delivery and painful intercourse postpartum, compared with vaginal delivery.

But why, if you had an exclusive cesarean, meaning you did not go through any labor or pushing prior to the delivery are you experiencing pelvic floor issues?

Your uterus is a pelvic organ

Your uterus is one of 3 pelvic organs. It is attached to the pelvic floor through fascia, ligaments and musculature. It just went through tremendous change during pregnancy, growing in size and moving into the abdomen. One of the 5 roles the pelvic floor plays is to support the position of the uterus, pregnant or not. During pregnancy the pelvic floor takes on more weight as baby, uterus, placenta all grow. As the uterus becomes larger and moves into the abdomen the ligaments that attach it to the pelvis stretch. The fascia connecting the uterus to the pelvic floor stretches. This all occurs prior to delivery and can change how the pelvic floor functions.

Your pelvic floor is 25% weaker from pregnancy alone

In addition to the changes mentioned above, the pelvic floor is influenced by bones of the pelvis during pregnancy. The further along you become the wider your bones become to accommodate baby. The combination of baby (& structures) added weight plus a wider pelvis weakens the pelvic floor by 25%. A weaker pelvic floor will not be able to respond optimally when you involuntarily or voluntarily call upon it to fulfill it’s roles. And may ultimately tighten up in response to not having strength to support your pelvic organs and joints.

Proximity of incision to the pelvic floor structures

The cesarean incision is made just above the pubic bone and goes through 7 layers of tissue. The front of the pelvic floor attached to the inner and underside of the pubic bone. Then fascia from the abdomen runs down inside the pubic bone into the pelvic floor. Scarring in the abdomen can cause restrictions in the muscles, fascia and organ tissue and pull or pucker surrounding (& even further away) tissue. The proximity of these tissues to your pelvic floor makes it more likely that the subsequent scarring will impact the pelvic floor.

The pelvic floor is part of a whole system that involves the abdomen

The pelvic floor works with the other deep core muscles to manage intraabdominal pressure and support your pelvic organs and joints. Even though muscle is not cut during a cesarean it is stretched and so is the fascia. The stretching these muscles go through, in addition to the scarring that weakens that line of tissue can cause the abdominal muscles not to respond with the rest of the system in a way that provides the necessary support. If one part of the system is failing the other areas either need to pick up the slack or will also start to fail.

The solution to this is not to do hundreds of kegels, because that only addresses one of these issues (maybe). It takes a combination of scar work at many layers, breathing exercises to connect to your pelvic floor, ensuring you don’t have a tense pelvic floor, coordination the pelvic floor and your abs, then progressively adding functional movements and exercises that match what your pelvic floor has to do to support your body throughout the day.

If you had a cesarean and are having pelvic floor (or other) problems, I encourage you to set up a consult call to discuss pelvic Physical Therapy.