Evidence Library · Your recovery

The pelvic floor, over years rather than weeks

Symptoms at three months are the best predictor of symptoms at four years and at twelve.

About one in three women has some urinary leakage in the first three months after birth: pooled prevalence 33% (95% CI 32 to 36). It is roughly twice as common after vaginal birth (31%) as after cesarean (15%). Across the first year, prevalence changes very little.

"Wait and see" is a plan for weeks, not for a yearIn 1,011 first-time mothers followed for four years, 29.6% still had urinary incontinence and 7.1% had faecal incontinence. Women with symptoms in the first year had 6 to 12 times the odds of urinary incontinence at four years.

In a separate cohort followed for twelve years, of the women who reported leaking at three months, 76.4% still reported it twelve years later.

Symptoms at three months are the strongest predictor there is. That is the moment to be referred, not the moment to be reassured.

Cesarean protects the pelvic floor only if every birth is a cesarean. At twelve years, women who had only cesareans had lower odds of incontinence than women who had only vaginal births (odds ratio 0.42). Women with a mix of both had odds of 1.01, which is to say no protection at all.

After a third or fourth degree tear, two findings run against what women are usually told. The chance of a repeat sphincter injury at the next birth is 6.1% in absolute terms, even though the relative risk of 4.9 times sounds much larger than that. And a cesarean next time has not been shown to protect against anal incontinence: comparing a second vaginal birth against a cesarean gave an odds ratio of 1.1, with a confidence interval from 0.9 to 1.4, which is no significant difference either way.

What the evidence says about pelvic floor exercises, preciselyThe Cochrane review covers 46 trials and 10,832 women. The strongest finding, at high-quality evidence, is for structured training started in early pregnancy in women who are still continent: 29% less incontinence at 3 to 6 months after birth (RR 0.71, 95% CI 0.54 to 0.95).

The reviewers are blunt about the other end: A population-based approach for delivering postnatal PFMT is not likely to reduce UI. Handing every new mother a leaflet does not work.

What is appropriate if you already have symptoms is an individual referral to a pelvic floor physiotherapist. The evidence in the first postpartum year is uncertain, and the evidence in mid-life women with the same symptoms is well established.

Where this comes from:

392. Thom DH, Rortveit G. Prevalence of postpartum urinary incontinence: a systematic review. Acta Obstet Gynecol Scand. 2010;89(12):1511-1522.

393. Gartland D, MacArthur C, Woolhouse H, McDonald E, Brown SJ. Frequency, severity and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort. BJOG. 2016;123(7):1203-1211.

222. MacArthur C, Wilson D, Herbison P, Lancashire RJ, Hagen S, Toozs-Hobson P, et al. Urinary incontinence persisting after childbirth: extent, delivery history, and effects in a 12-year longitudinal cohort study. BJOG. 2016;123(6):1022-1029.

394. Mørch EJ, Perslev K, Wrønding T, Aabakke A, Jangö H. Counseling women with obstetric anal sphincter injury: risk of recurrence and the influence of mode of second delivery on subsequent anal incontinence. A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2025;309:14-22.

224. Woodley SJ, Lawrenson P, Boyle R, Cody JD, Mørkved S, Kernohan A, et al. Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2020;(5):CD007471.

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This page is educational. It supports the conversation with your own clinicians. It is not consent to any treatment, and it cannot assess you. If you are worried about a symptom now, see urgent warning signs.