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Levator Avulsion: It doesn’t have to be the end of the world as you know it!

07 October, 2018

I am a great believer in empowering women (well everyone) with knowledge. Knowledge is very important- particularly knowledge based on evidence. For example- the world is not flat, climate change is real (just ask any farmer and those living in Greenland) and being kinder to refugees will give us more back than they take.

There is a debate in the obstetric and gynaecology (medical) world and women’s health physio circles that telling women about the extent of their birth injury may be a worry for women and cause more problems than it helps. And I certainly see that when seeing patients for the first time- they are often very anxious from what they have read on the internet in the various forums on Facebook and other sites and sometimes they don’t even have the problems/ injuries they had imagined they had.

Of course sometimes, many times they do have levator avulsion or nerve damage or micro-trauma causing stretching of the vaginal walls or prolapse. Because we tend to glorify the birth process (and it can be very glorious) there is often not a lot said about birth injuries prior to the birth that can happen to a woman with a vaginal delivery and which can ultimately be devastating to the future well-being of a woman.

Image demonstrating levator avulsion taken from the new edition of Pelvic Floor Essentials 2018 

But should we not fully inform women about the current status of their pelvic floor muscles? Shouldn’t we give them an opportunity to receive the information, process it, maybe grieve a bit and then move forward with a plan to maximise their potential of every skerrick of muscle they have left? Enable them to move forward with a plan to support their vaginal walls with a pessary to potentially protect against prolapse (if it will work) and a plan to get them exercising again in a manner that is relevant to their pelvic floor strength and other anatomical changes that have occurred with their vaginal delivery?

 

I believe that informing women about any birth injury they have is their right.

It is incomprehensible that we should keep the woman in the dark about their changed pelvic floor status. But we have to be there to give them encouragement, motivation and a positive plan of moving forward based on evidence not just dramatically tell them about the damage/changes and leave them dangling and unsupported emotionally, psychologically and physically.

I recently received an article by Alexandre Fornari & Cristiane Carboni which reviewed all the articles referencing pelvic floor physiotherapy as a modality for the treatment of pelvic floor dysfunctions. The aim of this study was to identify and characterize the most frequently cited articles on pelvic floor physiotherapy published in the last 30 years. Between 1983 and 2013 (30 years) there were 1,285 articles published (among them there were 12 randomized clinical trials (RCTs) and 4 reviews). The most common topics among the classic articles were behaviour therapy, pelvic floor muscle training (PFMT), biofeedback-assisted PFMT, and neuromuscular electrical stimulation.

In 2017, the same authors conducted a new search for papers on pelvic floor physiotherapy using the same methods to compare them with the 2013 data and they found 1,745 papers containing the term pelvic floor physiotherapy, indicating an increase of around 35% in 4 years. The authors concluded that ‘pelvic floor physiotherapy is an emergent sub-specialty where scientific knowledge is evolving fast. This is seen not only in numbers, as demonstrated by our quantitative results, but also in quality, as seen in the high-level evidence presented by the classic studies analyzed in our research’.

When I revised and updated both editions of my books Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Surgery and Pelvic Floor Essentials I wanted to include as much evidence in the books about rehabilitation of the bladder, bowel and pelvic floor as I could, while still making them readable and easily understood by the target audience – which is the lay person in the community. I wanted to translate seemingly complex concepts into easily understood strategies that the woman could begin to implement- particularly if she is a regional area without access to a pelvic health physiotherapist. But if you can access a pelvic health physio, always do so for that individualised, personal assessment and treatment.

If you have concerns about your pelvic floor (or your bladder or bowel function or pelvic pain) then find yourself a pelvic floor physio to mentor you and to assist you to obtain a fantastic recovery from your birth experience in the short-term, medium term and long-term.

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