Pelvic Floor Injury During Childbirth: All About Levator Ani Avulsion
- Written by Carly Cano
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First: Understand your pelvic anatomy to better understand your injury
The pelvic floor is a group of muscles positioned like a hammock along our saddle region.
Levator ani avulsion occurs when muscle fibers of the puborectalis (the innermost muscle of the pubococcygeus group) are detached from its insertion on the pubic bone. This is somewhat frequently occurring, and about 20% of women experience an avulsion during their first vaginal childbirth. Risk factors include instrumental-assisted delivery (forceps presenting a higher risk than vacuum), older age at vaginal birth, second stage lasting longer than 2 hours, baby weighing over 8 pounds and 13 ounces, and those who had a grade 4 perineal tear.
What does this mean for folks that have this injury?
Prolapse and Decreased Vaginal Sensation are common with a Levator Ani Avulsion
Pelvic organ prolapse is a weakening of the pelvic support system (fascia, ligaments, muscles) that leads to a descent or shift of organs bulging onto the vaginal wall.
Women with prolapse often complain of a vaginal bulge, heaviness in vagina, or like an old/dry tampon “hanging” out. Symptoms often increase with standing, lifting, after having a bowel movement and often improve in a restful lying down position. Researchers have found that women with avulsion tend to have a larger levator hiatus size (vaginal canal opening) and decreased strength in pelvic floor muscles compared to those without. These two factors are likely contributors to a decreased support system leading to prolapse. Another common complaint is decreased vaginal sensation, which can lead to decreased pleasure during sexual activity. One study found that at six months postpartum, those with levator ani avulsion following a forceps-assisted delivery reported a decrease in these categories: arousal, natural vaginal lubricant, orgasm, and sexual satisfaction compared to their counterparts.
What can we do?
Pelvic floor physical therapists also assess and treat other common postpartum conditions such as:
- Neck/midback/lowback pain
- Bladder/Bowel symptoms (too much or too little, incontinence, pain, straining, etc.)
- Movement patterns with baby (holding, breastfeeding, lifting)
- Return to regular activity and/or exercise
- Return to sexual activity/pain-free sexual activity
There is help and specialized pelvic floor physical therapists are here for you!
Cassadó J, Simó M, Rodríguez N et al. Prevalence of levator ani avulsion in a multicenter study (PAMELA study). Archives of Gynecology and Obstetrics. 2020; 302:273–280 https://doi.org/10.1007/
Lien K, Mooney B, DeLancey JOL, and Ashton-Miller JA. Levator Ani Muscle Stretch Induced by Simulated Vaginal Birth. Obstet Gynecol. 2004; 103(1): 31-40.
Handa VL, Roem J, Boaquist JL, et al. Pelvic organ prolapse as a function of levator ani avulsion, hiatus size, and strength. Am J Obstet Gynecol. 2019; 221(1): 41.e1–41.e7. doi:10.1016/j.ajog.2019.03.
Handa VL, Blomquist JL, Roem J, et al. Levator morphology and strength after obstetrical avulsion of the levator ani muscle. Female Pelvic Med Reconstr Surg. 2020; 26(1): 56-60. doi:10.1097/SPV. 0000000000000641