Was your levator avulsion injury missed or dismissed — and could that be medical negligence?

Understanding levator avulsion: what normally happens

The levator ani is a group of muscles that form the floor of the pelvis. These muscles support the bladder, bowel, and uterus. During a vaginal birth, these muscles stretch enormously. In some births — particularly those involving forceps, a large baby, or a prolonged pushing stage — one or more of these muscles can tear away from the pubic bone entirely. This is called a levator avulsion injury.

Levator avulsion is not a rare event. Research suggests it occurs in roughly one in three instrumental vaginal deliveries. Despite this, many women are never told it happened. Many are not examined for it. And many spend years living with symptoms they were told were simply “normal after having a baby.”

Proper care after a birth that carries a high risk of this injury involves a structured postnatal assessment. A clinician should examine the pelvic floor, ask about symptoms, and consider imaging if there is any concern. If an avulsion is found, the woman should be told clearly what it means, what her long-term risks are, and what treatment options exist. For general information about pelvic floor health and postnatal recovery, Healthdirect Australia provides accessible, evidence-based guidance.

When things start to go wrong

Some symptoms after birth are expected and resolve within weeks. Mild soreness, some urinary leakage in the first few days, and general pelvic heaviness are common. But certain symptoms point to something more serious. The problem is that many women are told all postnatal symptoms are normal — and they believe it, because they trust their care team.

Any one of these symptoms, particularly after an instrumental delivery, should have prompted a clinician to examine the pelvic floor carefully and consider imaging. If your symptoms were dismissed or attributed to normal postnatal recovery without proper examination, that response may not have met the standard of care.

A common pattern — where care can break down

Levator avulsion injuries follow a recognisable pattern of failure in the healthcare system. These failures do not always happen because a clinician was careless. Sometimes they happen because of time pressure, poor documentation, or a lack of awareness. But the law does not require bad intent — it requires that care met an acceptable standard. The Australian Commission on Safety and Quality in Health Care sets national standards for postnatal care that include structured assessment of pelvic floor function.

No postnatal pelvic floor assessment. Many women are discharged from hospital without any structured examination of the pelvic floor. A midwife or obstetrician who does not assess pelvic floor function after an instrumental delivery has missed a critical step in postnatal care.

Symptoms dismissed as normal. Women who report pelvic heaviness, prolapse symptoms, or incontinence are sometimes told this is expected after childbirth. While some degree of pelvic floor change is normal, persistent or worsening symptoms are not. Dismissing them without examination is a failure to investigate.

No referral for imaging. Translabial ultrasound is the standard tool for diagnosing levator avulsion. A clinician who suspects pelvic floor injury but does not arrange imaging — or does not refer to a specialist who can — has failed to take a step that a competent clinician would have taken.

Failure to refer to a specialist. Even where a GP or midwife identifies pelvic floor symptoms, a failure to refer promptly to a urogynaecologist or pelvic floor physiotherapist can delay diagnosis and treatment. That delay can allow prolapse to worsen significantly.

No informed consent about future risks. A woman who has sustained a levator avulsion has a substantially elevated risk of pelvic organ prolapse. She has a right to know this. If she was not told, she could not make informed decisions about future pregnancies, physical activity, or treatment.

Why this matters legally

Every clinician who treats a patient owes that patient a duty of care — a legal obligation to provide treatment that meets the standard of a competent professional in the same field. This duty applies to obstetricians, midwives, GPs, and any other clinician involved in your postnatal care.

Not every difficult birth outcome is negligence. Levator avulsion can occur even when every step of care was performed correctly. The injury itself is not automatically evidence of wrongdoing. What matters legally is whether the clinician’s response to the birth — and to your symptoms afterwards — met the standard expected of a competent practitioner.

If a clinician failed to assess, failed to investigate, failed to diagnose, or failed to tell you what had happened and what it meant for your future health, those failures may constitute a breach of the duty of care. For a broader understanding of how this legal framework applies to birth-related injuries, see Reframe Legal — Medical Negligence.

When levator avulsion may amount to medical negligence

The NSW Civil Liability Act 2002 is the main law that governs medical negligence claims in this state. In plain terms, it sets out that a clinician is negligent if they failed to act in a way that a reasonable body of professionals in the same field would have acted — and that failure caused harm.

In the context of levator avulsion, the following situations may give rise to a negligence claim:

• If you had a forceps delivery and no one examined your pelvic floor before you left hospital, and you later developed a significant prolapse that required surgery, the failure to assess may have contributed to the harm.
• If you reported symptoms of prolapse or incontinence at your six-week check and your GP or obstetrician told you it was normal without examining you, that dismissal may have been a breach of the duty of care.
• If imaging was eventually performed and showed a levator avulsion, but no one told you what that meant or referred you to a specialist, the failure to inform and refer may have caused ongoing harm.
• If you went on to have another vaginal birth without being told about your elevated risk of worsening prolapse, the failure to provide that information may have affected your ability to make an informed choice about your delivery method.
• If your prolapse was eventually diagnosed as severe — requiring mesh surgery or other significant intervention — and an earlier diagnosis would have allowed less invasive treatment, the delay itself may be the source of the harm.

When harm becomes long-term or permanent

Levator avulsion does not always cause immediate, obvious harm. The injury itself may be silent for months or years. But over time — particularly with subsequent pregnancies, physical activity, or simply ageing — the consequences can become severe and life-altering.

• 1
  Immediately after birthThe avulsion has occurred. Symptoms may be mild or attributed to normal postnatal recovery. No assessment is performed. The injury goes undetected.
• 2
  Weeks to months laterPelvic heaviness, leakage, or a bulging sensation develops. The woman raises it with her GP or obstetrician. She is told it is normal and will improve with pelvic floor exercises.
• 3
  One to three years laterSymptoms worsen. A second pregnancy may have occurred without knowledge of the elevated risk. Prolapse becomes more pronounced. Daily activities — exercise, lifting, standing — become difficult or painful.
• 4
  Three to ten years laterA urogynaecologist finally diagnoses the levator avulsion and a significant prolapse. Surgery is recommended. The woman learns for the first time that this injury occurred at her birth years earlier.
• 5
  Long-term consequencesOngoing pelvic pain, sexual dysfunction, urinary and bowel symptoms, psychological distress, and the physical and financial burden of surgery and rehabilitation — all of which may have been reduced or avoided with earlier diagnosis and management.

The psychological consequences of this journey are significant. Many women describe feeling dismissed, embarrassed, and isolated. They blame themselves for not pushing harder for answers. They grieve the loss of physical function and intimacy. These are real harms — and the law recognises psychological injury as a compensable loss alongside physical harm.

What compensation can cover in levator avulsion cases

In NSW, compensation in a medical negligence claim can cover a range of losses. These include pain and suffering, loss of enjoyment of life, past and future medical expenses, the cost of surgery and rehabilitation, lost income if the injury affected your ability to work, and the cost of care and assistance you needed as a result of the harm.

Each case is assessed on its own facts. These figures are general ranges only. The severity of your prolapse, the number of surgeries required, the impact on your daily life and relationships, and the length of time you lived without a diagnosis all affect the value of a claim.

Time limits apply in NSW. In most cases, a medical negligence claim must be commenced within three years of the date you knew — or ought reasonably to have known — that you had suffered harm as a result of negligent care. Because levator avulsion is often diagnosed years after the birth, the question of when time begins to run can be complex. This is something a lawyer with experience in this area can help you work through.

Bringing it together — do the pieces fit?

You may be reading this article because something does not sit right with you. You had a difficult birth. You reported symptoms. You were told they were normal. Years passed. And now you have a diagnosis — or you are still searching for one — and you are wondering whether the care you received was good enough.

These are the questions worth sitting with:

• Was your pelvic floor examined before you left hospital after your birth?
• Were you told that your delivery carried a higher risk of pelvic floor injury?
• When you reported symptoms, were you examined — or just reassured?
• Were you ever referred for imaging or to a specialist?
• Were you told about the long-term risks of levator avulsion before you made decisions about future pregnancies?
• Has your prol