European Journal of Cardiovascular Medicine

Pelvic floor dysfunction (PFD) is a common complication affecting women after childbirth, with potential long-term consequences such as urinary incontinence, fecal incontinence, pelvic organ prolapse, and sexual dysfunction. The physiological and mechanical stress imposed on pelvic structures during vaginal delivery is a key factor in the development of these disorders (1). Among various delivery methods, instrumental vaginal delivery (IVD), including forceps or vacuum assistance, has been associated with a higher risk of maternal perineal trauma and subsequent PFD compared to spontaneous vaginal delivery (SVD) (2).

The process of childbirth may damage the pelvic floor muscles, fascia, and pudendal nerves, contributing to the development of dysfunction. The use of obstetric instruments can exacerbate this damage due to increased traction and compression forces during delivery (3). Several studies have demonstrated a higher incidence of levator ani muscle avulsion and pudendal nerve injury in women who underwent IVD, which are strongly linked with postpartum PFD symptoms (4,5).

While short-term studies have explored the association between delivery mode and early postpartum pelvic floor outcomes, longitudinal studies assessing the persistence and progression of PFD over time remain limited. Understanding the long-term implications of IVD versus SVD on pelvic floor health is crucial for guiding delivery decisions and postpartum care strategies (6). Therefore, this study aims to assess and compare the incidence and progression of pelvic floor dysfunction in primiparous women who underwent instrumental versus spontaneous vaginal delivery over a one-year postpartum period.

This prospective longitudinal cohort study was conducted at a tertiary care center. A total of 240 primiparous women who underwent vaginal delivery were recruited and categorized into two groups: spontaneous vaginal delivery (SVD, n=120) and instrumental vaginal delivery (IVD, n=120). Instrumental delivery included the use of either vacuum or forceps assistance during childbirth. Women with a history of pelvic floor dysfunction prior to pregnancy, cesarean section, multiple gestations, or obstetric complications such as third- or fourth-degree perineal tears were excluded.

Data on maternal demographics, obstetric details, and mode of delivery were collected from hospital records. Pelvic floor function was evaluated using two standardized tools: the Pelvic Floor Distress Inventory-20 (PFDI-20) questionnaire and the Pelvic Organ Prolapse Quantification (POP-Q) system. Assessments were carried out at three time points: 6 weeks, 6 months, and 12 months postpartum.

In addition to the PFDI-20 and POP-Q, specific symptoms including urinary incontinence, fecal incontinence, and sexual dysfunction were recorded using validated symptom-specific questionnaires. All clinical examinations were performed by trained gynecologists blinded to the delivery mode of the participants to minimize assessment bias.

Data were entered into a secured database and analyzed using SPSS version 25. Descriptive statistics were used to summarize demographic characteristics. Comparative analysis between groups was conducted using Chi-square tests for categorical variables and independent t-tests for continuous variables. A p-value of <0.05 was considered statistically significant

A total of 240 primiparous women were included in the final analysis, equally divided between the spontaneous vaginal delivery group (SVD; n=120) and the instrumental vaginal delivery group (IVD; n=120). The baseline demographic and obstetric characteristics were comparable between the two groups, as shown in Table 1. The mean maternal age was 27.3 ± 3.9 years in the SVD group and 26.8 ± 4.1 years in the IVD group (p = 0.41). The mean birth weight of neonates was slightly higher in the IVD group (3.42 ± 0.38 kg) compared to the SVD group (3.29 ± 0.35 kg; p = 0.03).

At 6 weeks postpartum, the prevalence of moderate to severe pelvic floor symptoms (PFDI-20 score ≥ 60) was significantly higher in the IVD group (n=58; 48.3%) compared to the SVD group (n=32; 26.7%) (p < 0.01). At 6 months, 39.1% of women in the IVD group and 22.5% in the SVD group continued to report symptoms. By 12 months postpartum, symptom persistence was observed in 35.8% of the IVD group and 18.3% of the SVD group (p = 0.02), as presented in Table 2.

Pelvic organ prolapse quantification (POP-Q) results indicated a higher frequency of stage II prolapse in the IVD group at 12 months (n=33; 27.5%) compared to the SVD group (n=13; 10.8%) (p = 0.01). Urinary incontinence remained the most reported complaint at all three time points in the IVD group, followed by a sensation of pelvic pressure and dyspareunia (Table 3).

Table 1: Baseline Demographic and Obstetric Characteristics

Table 2: Prevalence of Pelvic Floor Dysfunction Symptoms Over Time

Table 3: Distribution of Specific Pelvic Floor Symptoms at 12 Months

These results indicate a consistent trend of higher prevalence and persistence of pelvic floor dysfunction in women who underwent instrumental vaginal delivery, particularly in terms of urinary incontinence and pelvic support defects (Table 2, Table 3).

This longitudinal study assessed the impact of mode of vaginal delivery—instrumental versus spontaneous—on the development and persistence of postpartum pelvic floor dysfunction (PFD) over a one-year period. The results demonstrated that women who underwent instrumental vaginal delivery (IVD) had a significantly higher prevalence of moderate to severe pelvic floor symptoms, particularly urinary incontinence and pelvic organ prolapse, compared to those who delivered spontaneously (SVD).

Previous literature has well established the role of vaginal delivery as a primary risk factor for pelvic floor damage, with instrumental deliveries posing a greater risk due to excessive mechanical stress and soft tissue trauma during birth (1,2). Our findings are consistent with earlier studies which reported increased rates of levator ani avulsion and pudendal nerve injury following forceps and vacuum deliveries (3,4). These injuries are often subclinical at the time of delivery but manifest as functional impairments months or years later (5).

The significantly higher PFDI-20 scores observed in the IVD group at 6 weeks, 6 months, and 12 months postpartum suggest that damage incurred during assisted delivery may have lasting effects on pelvic floor integrity (6). This finding is aligned with results from DeLancey et al., who demonstrated that muscle trauma during delivery is a key contributor to pelvic support disorders (7). Furthermore, the higher incidence of stage II pelvic organ prolapse in the IVD group corroborates reports by Chan et al. and others who identified operative vaginal delivery as a strong predictor of pelvic organ descent (8,9).

Urinary incontinence was the most prevalent symptom in our cohort, particularly in the IVD group. This is supported by multiple studies which emphasize the increased risk of stress incontinence following instrument-assisted deliveries (10,11). The link between prolonged second-stage labor, perineal lacerations, and subsequent incontinence symptoms has also been discussed extensively in recent meta-analyses (12,13).

Interestingly, dyspareunia and fecal incontinence were also reported more frequently among women in the IVD group, albeit to a lesser extent. These symptoms may be associated with perineal trauma, altered neuromuscular function, and changes in pelvic floor elasticity (14). While the overall incidence of fecal incontinence was low in both groups, its higher occurrence in the IVD group highlights the broader spectrum of pelvic floor impairments that can result from assisted vaginal delivery.

Our findings underscore the importance of early postpartum screening and rehabilitation programs targeting pelvic floor health, especially for women who undergo IVD. Pelvic floor muscle training (PFMT), under physiotherapist supervision, has been shown to be effective in reducing the severity and progression of PFD symptoms (15). Healthcare providers should incorporate such preventive strategies in routine postpartum care.

Limitations of this study include its single-center design and reliance on self-reported symptoms, which may introduce recall bias. Furthermore, the study excluded women with cesarean deliveries and severe obstetric complications, which limits generalizability. Future studies should incorporate imaging modalities such as translabial ultrasound or MRI to provide objective measures of pelvic floor injuries.

Instrumental vaginal delivery is significantly associated with a higher risk and prolonged persistence of postpartum pelvic floor dysfunction compared to spontaneous vaginal delivery. Early identification, routine pelvic floor assessment, and postpartum rehabilitation strategies are essential to minimize long-term morbidity and improve quality of life in affected women.

1. Borges AC, Sousa N, Sarabando R, Vieira C, Ribeiro B, Barbosa P, et al. Pelvic floor dysfunction after vaginal delivery: MOODS—a prospective study. Int Urogynecol J. 2022 Jun;33(6):1539–47. doi:10.1007/s00192-021-04982-w.
2. Rodrigues S, Silva P, Borges AC, de Sousa NQ, Silva JN, Escuriet R. Effect of perineal massage and warm compresses technique in postpartum pelvic floor dysfunction: a secondary analysis from a randomised controlled trial. Reprod Sci. 2024 Apr;31(4):1006–16. doi:10.1007/s43032-023-01424-4.
3. Crane AK, Geller EJ, Bane H, Ju R, Myers E, Matthews CA. Evaluation of pelvic floor symptoms and sexual function in primiparous women who underwent operative vaginal delivery versus cesarean delivery for second-stage arrest. Female Pelvic Med Reconstr Surg. 2013 Jan-Feb;19(1):13–6. doi:10.1097/SPV.0b013e31827bfd7b.
4. de Sousa NQ, Borges AC, Sarabando R, Bivar L, Viana J, Cerqueira M, et al. The role of operative vaginal delivery in postpartum sexual dysfunction: MOODS – a prospective study. J Sex Med. 2021 Jun;18(6):1075–82. doi:10.1016/j.jsxm.2021.04.002.
5. Zhou Y, Luo Y, Zhou Q, Xu J, Tian S, Liao B. Effect of gestational weight gain on postpartum pelvic floor function in twin primiparas: a single-center retrospective study in China. BMC Pregnancy Childbirth. 2023 Apr 20;23(1):273. doi:10.1186/s12884-023-05602-9.
6. Iris S, Yael B, Zehava Y, Ella P, Hannah G, Miriam E, et al. The impact of breastfeeding on pelvic floor recovery from pregnancy and labor. Eur J Obstet Gynecol Reprod Biol. 2020 Aug;251:98–105. doi:10.1016/j.ejogrb.2020.04.017.
7. Speksnijder L, Oom DMJ, Van Bavel J, Steegers EAP, Steensma AB. Association of levator injury and urogynecological complaints in women after their first vaginal birth with and without mediolateral episiotomy. Am J Obstet Gynecol. 2019 Jan;220(1):93.e1–7. doi:10.1016/j.ajog.2018.09.025.
8. Karaaslan Y, Karadag M, Toprak Celenay S. Pelvic floor dysfunction symptoms and knowledge level in obese women. Women Health. 2022 Apr;62(4):293–301. doi:10.1080/03630242.2022.2064034.
9. Zhang X, Zhang X, Wang Y, Huang X, Chen X, Wang L. Short-term effects of delivery methods on postpartum pelvic floor function in primiparas: a retrospective study. Ann Palliat Med. 2021 Mar;10(3):3386–95. doi:10.21037/apm-21-485.
10. Froeliger A, Mattuizzi A, Madar H, Hamel JF, Bouchghoul H, Sentilhes L. Maternal and neonatal morbidity after attempted operative vaginal delivery. Obstet Gynecol. 2022 May;139(5):833–45. doi:10.1097/AOG.0000000000004746.
11. Nygaard IE, Wolpern A, Bardsley T, Egger MJ, Shaw JM. Early postpartum physical activity and pelvic floor support and symptoms 1 year postpartum. Am J Obstet Gynecol. 2021 Feb;224(2):193.e1–19. doi:10.1016/j.ajog.2020.08.033.
12. Sánchez Sánchez B, Torres Lacomba M, Navarro Brazález B, Cerezo Téllez E, Pacheco Da Costa S, Gutiérrez Ortega C. Responsiveness of the Spanish Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaires short forms (PFDI-20 and PFIQ-7) in women with pelvic floor disorders. Eur J Obstet Gynecol Reprod Biol. 2015 Jul;190:20–5. doi:10.1016/j.ejogrb.2015.03.029.
13. Sigurdardottir T, Bø K, Steingrimsdottir T, Halldorsson TI, Aspelund T, Geirsson RT. Cross-sectional study of early postpartum pelvic floor dysfunction and related bother in primiparous women 6–10 weeks postpartum. Int Urogynecol J. 2021 Jul;32(7):1847–55. doi:10.1007/s00192-021-04813-y.
14. Boujenah J, Tigaizin A, Fermaut M, Murtada R, Benbara A, Benchimol M, et al. Is episiotomy worthwhile to prevent obstetric anal sphincter injury during operative vaginal delivery in nulliparous women? Eur J Obstet Gynecol Reprod Biol. 2019 Jan;232:60–4. doi:10.1016/j.ejogrb.2018.11.014.

15. Colla C, Paiva LL, Ferla L, Trento MJB, de Vargas IMP, Dos Santos BA, et al. Pelvic floor dysfunction in the immediate puerperium, and 1 and 3 months after vaginal or cesarean delivery. Int J Gynaecol Obstet. 2018 Oct;143(1):94–100. doi:10.1002/ijgo.12561.