Pelvic floor injury after birth · Part 2 of 5
Levator Avulsion: The Birth Injury No One Told You About
In this article
Perhaps you've just been handed the words "levator avulsion" after a scan. Or perhaps you're searching because something has felt wrong since your birth and no one can tell you why. Either way, this article explains what the injury is, how it's diagnosed, why forceps matter, and why so many women wait so long for answers. I'll also talk about what a diagnosis can mean, beyond the medical.
This series: pelvic floor injury after birth
- Prolapse after a forceps birth: when it isn't just "normal"
- Levator avulsion: the injury no one told you about (you are here)
- "Why didn't anyone tell me forceps could do this?"
- "It's normal after a baby": when pelvic floor symptoms are dismissed
- Living with a pelvic floor injury, and what a claim can cover
A name, finally.
For some women, hearing the words levator avulsion comes as a strange kind of relief.
After months, sometimes years, of being told it was weak muscles, or not enough pelvic floor exercises, or "just having a baby", there's finally a name for it.
Something actually happened to your body.
And then, often quite quickly, the relief turns into something else. Grief. Anger. A long list of questions. Why did no one find this sooner? Could it have been avoided? Why did nobody mention this was possible?
You're not overreacting. Those are exactly the right questions.
What levator avulsion is
Levator ani and levator avulsion
The levator ani is the main muscle of the pelvic floor. It wraps around the vagina, urethra and back passage like a sling, supporting your pelvic organs. An avulsion is when part of that muscle tears away from where it attaches to the pubic bone.
In plain terms: the muscle that holds everything up has come away from its anchor point. And unlike a tear in skin, it doesn't simply grow back.
Professor Hans Peter Dietz describes avulsion as the most common form of major levator trauma. He has written that it enlarges the opening in the pelvic floor and reduces the muscle's strength by about a third. Research also shows that women with an avulsion have markedly weaker pelvic floor muscles on examination.
That loss of support is linked to prolapse, which is often the symptom that brings women to a doctor in the first place. The common signs are heaviness, bulging, leaking, difficulty emptying the bladder or bowel, and changes during sex. Queensland Health lists the signs of prolapse here.
How it happens, and the forceps question
Avulsion happens during vaginal birth, when the pelvic floor is stretched beyond what it can tolerate. Some women are more vulnerable than others. But the way a birth is managed matters, too.
In a study of first-time mothers, researchers found that forceps and a longer pushing stage were associated with levator trauma. Avulsion occurred in 13% of vaginal births in that study, and in none of the caesareans.
Research has also tried to understand why forceps carry such a risk. One study concluded that the effect of forceps isn't fully explained by the extra space the instrument takes up. The speed and force involved may also play a part.
And among women attending a urogynaecology clinic after a forceps birth, researchers found that close to half had a levator avulsion.
Let me be clear about what this does and doesn't mean. It doesn't mean every forceps birth is negligent. Sometimes forceps are the safest option in a genuine emergency. But it does mean the decision to use them is a significant one, with real risks to you. Those risks should be weighed carefully, and you should have been told about them. I explore that in Part 3 of this series.
If this is landing for you, and you're putting pieces together about your own birth, I'd be glad to talk it through with you. You don't need to have all the answers first.
Why it's so often missed
Here's something that surprises a lot of women. An avulsion usually can't be seen from the outside.
Unlike a tear in the skin, it sits deeper inside. It's often missed in a standard check after birth, or put down to general weakness at the six-week appointment. Specialist imaging is usually needed to confirm it. The Australian Physiotherapy Association notes that injuries like this can be detected with 3D/4D pelvic floor ultrasound, with referral to a urogynaecologist where needed.
The result is that many women spend a long time being reassured. Amy Dawes, co-founder of the Australasian Birth Trauma Association, has written about her own avulsion being diagnosed 16 months after her birth. She describes how often women's symptoms are dismissed as just their new normal. She has also spoken publicly about how much that wait cost her emotionally.
She isn't alone. Australian research reported back in 2017 suggested that around one in five first-time mothers sustain major pelvic floor or anal sphincter trauma. Many of these injuries are only recognised much later.
If you've been brushed off along the way, I've written specifically about that in Part 4: "It's normal after a baby".
What a diagnosis can mean for you
Medically.
A diagnosis helps your treating team choose the right care. The options for related prolapse range from physiotherapy and pessaries to surgery. The Australian Commission on Safety and Quality in Health Care has a consumer guide to treatment options for prolapse. Pelvic Floor First has practical information on caring for your pelvic floor.
Legally.
Standard of care and causation
A negligence claim asks whether your care fell below what a competent clinician should have provided, and whether that failure caused your injury, or made it worse.
In plain terms: was something done, or not done, that a careful team wouldn't have? And did it make the difference?
With levator avulsion, the questions usually centre on a few things. Were forceps truly necessary? Were you told the risks? Was the birth managed properly? And was your injury recognised and treated when it should have been? A diagnosis is often the moment those questions become answerable.
The timing of your diagnosis can also matter for legal time limits. I explain more in Part 5.
Emotionally.
Please be kind to yourself here. A diagnosis can stir up grief about your birth, your body, and the time you lost to not knowing. Birth Trauma Australia offers peer support from women who've lived this. PANDA's helpline is on 1300 726 306.
Frequently asked questions
Can a levator avulsion be repaired?
That's a question for your treating specialist, and the answer depends on your situation. Many women manage symptoms with physiotherapy and pessaries. Some need surgery for related prolapse.
I didn't have forceps. Could I still have an avulsion?
Yes. Avulsion can happen in other vaginal births too. Forceps increase the risk, but they're not the only factor.
I also had a severe tear. Are they related?
They can happen in the same birth. You may find my article on third and fourth degree tears useful.
Do I need to have a scan before talking to a lawyer?
No. Many women contact me before they have a formal diagnosis. Getting the right assessment can be part of the process.
A closing thought
For so long, you may have wondered whether you were imagining it, or whether you just weren't trying hard enough with your exercises.
You weren't imagining it. And this was never about trying harder.
So I'll leave you with this: now that your injury has a name, what do you most need to understand about how it happened?
This article is general information only. It is not legal or medical advice, and reading it does not create a lawyer–client relationship. Every situation is different. If you are in crisis, please call Lifeline on 13 11 14 or 000 in an emergency.
