Angela James: So that would indicate she has some form of stress urinary incontinence which means there’s something not quite right with the control around the bladder and the urethra. I would suggest that a great place to start is to see a pelvic health physiotherapist to assess the different contributors to the issue.
The physiotherapist would look at her pelvic floor muscle function and assess how strong the pelvic floor muscle is as well as how coordinated the pelvic floor muscle is. They would potentially look at other contributing factors like what’s happening in her overall fluid intake, what’s happening in her bowel, those sorts of things.
Without an examination it’s hard to say exactly what’s causing it, but it certainly sounds like a symptom of stress incontinence indicating that the continence mechanism isn’t working perfectly, which is very common after childbirth.
Side view of new mother comforting her newborn while crying. Baby getting used to noises and lights in her first days of life outside the womb. Source: Moment RF / Juanma hache/Getty Images
Fiona Reid: Where there’s any trauma in any delivery, in any birth, the trauma has to be addressed first. So, when preparing to have a vaginal birth after caesarean it’s very important to have parallel care so that any unresolved trauma is addressed.
Then the nature of that previous labour and birth needs to be assessed clinically and physiologically. So, what happened during the course of labour? How did it progress or how didn’t it progress? Why didn’t it? Looking at that very carefully and then the care provider must look at what the woman wants. Often where there’s trauma, women have already identified what they will or will never do again, what they want and what they don’t want ever again. It sort of crystallises after the event – and they are both physical and psychological things. In clinical care that all has to be taken into account when planning for a vaginal birth after caesarean.
Angela James: There are a few different parts of your initial consultation. Firstly, there would be a lot of questioning, for example, what happened before pregnancy? Was there any childhood incontinence? What kind of sports did the woman play? What kind of load has been put on the pelvic floor prior to pregnancy and what were the symptoms like during pregnancy? There would be a lot of questioning around the birth, whether it was a vaginal birth or caesarean section.
The physiotherapist would look at risk factors such as use of forceps or if it was a fast delivery, the size of the baby and any other risk factors that would indicate there would be more injury to the pelvic floor muscle.
Once that’s been established they would ask if there are symptoms and how that may be interrupting her life and what her goals are in terms of exercise or whatever it is that she wants to return to, or achieve, in this sort of postpartum space.
There does need to be some form of physical exam but there are different options. It can be an ultrasound assessment, which allows the pelvic health physio to see the pelvic floor move and it allows the physio to see the abdominal muscles to see if they are working correctly. Another physical examination option would be observation of the vulva and the perineal area which allows them to see whether the pelvic floor is working and you can see if there’s the presence of prolapse. They can also assess any scarring and healing.
Prolapse occurs when the ligaments that hold the pelvic organs – bladder, uterus, cervix, vagina, and rectum – in place are stretched or weakened. Without the support, the uterus can drop forward all the way into the vaginal passage.
A third option could be an internal examination, which is a lubricated gloved digital examination using one finger or two, depending on what’s going on in the pelvic floor, and that gives us more information around how the pelvic floor has changed during birth.
It’s common to have an internal examination but if for whatever reason the woman’s not comfortable with that, there are those other options so it doesn’t need to be a barrier to having a pelvic health consultation.
I think the best birth plans are those that are handwritten and on one page of paper….
Angela James: Yes certainly, because it’s not just the birth that changes the female body. We know that about 50 per cent of women’s symptoms postnatally are to do with pregnancy and 50 per cent is due to the sort of mode of delivery.
During pregnancy, the pelvic floor weakens because of the the weight. It’s like a little baby elephant sitting on a trampoline, so women can still certainly experience urinary incontinence then, but with a c-section they are not as likely to experience prolapse as that’s something that’s more to do with pushing the baby out.
The other aspect that changes with a caesarean section is the surgery itself. With a c-section, the layers of the abdominal muscles need to be cut through so there needs to be attention to rehabilitation of the abdominal wall and also addressing the overall pelvic floor muscle function because the prevalence rates for urinary incontinence is exactly the same with c-section versus vaginal birth.
Fiona Reid: We have an increasing number of women who are requesting a caesarean following a traumatic vaginal birth and there’s definitely a place for that. Agency over their bodies, their experience, what they will and won’t consent to, is extraordinarily important for women to survive labour and birth in good condition.
For a woman who has experienced birth trauma, a caesarean is not a clinical decision.That is up to the woman to make that decision about how traumatised she is following the birth of a baby and a request for caesarean during the pregnancy, and early, if she’s feeling like that, should be investigated and supported in any way the hospital can.
Fiona Reid: That depends on the midwife’s personality really. Some midwives remain curious, compassionate, concerned, and very woman-focused for their entire careers and other midwives are burnt out, resistant to being told how to do their jobs and dismissive about women saying what they would and wouldn’t like at the time of labour and birth.
I think the best birth plans are those that are handwritten and on one page of paper and then it carries a very personal message about the individuals that you have in front of you and I think clinicians are less likely to be resistant to that.
Angela James: I would strongly advocate for a postnatal physical assessment from a pelvic health physiotherapist to look at pelvic floor muscle function and abdominal muscle function to work out what level of function the pelvic floor is at before returning to sport.
There’s normally some compromise of the pelvic floor that needs to be improved before returning to more vigorous exercise.
The hard thing is you don’t know how everything is sitting until you’ve had that assessment, so you could feel fine with normal everyday activities but if you then go and do something a little more intense like run or jump on hop or skip that’s when symptoms can reveal itself and obviously it’s better practise to really assess beforehand and rehabilitate and then load just like we would for any other type of injury.
This week is birth trauma awareness week. The Australasian Birth Trauma Association (ABTA) is hosting a series of online Q&As with medical and health professionals. You can watch the videos
. ABTA is also hosting its annual Walk n Support fundraising events across the country on Sunday 24 July. You can find out more at