Will a Second Pregnancy Make Everything Worse?

The Levator Ani muscle is a group of muscles that make up part of the pelvic bowl. It is comprised of 3 muscles: puborectalis, pubococcygeus and iliococcygeus. For this blog, we will just reference them as “Levator Ani muscle”. During vaginal delivery pelvic trauma can occur in which these muscles can be torn away from the pubic bone resulting in an avulsion injury.

The incidence of levator ani avulsion has been reported in 10-30% of first-time vaginal births. (Subramaniam, N. et al 2019). The use of forceps is the main risk factor in levator ani avulsion injuries. (Dietz, H. et al 2012 & Subramanam, N. et al 2019). Other risk factors include large fetal head circumference, prolonged second stage labour, high birth weight of the baby. (Garcia-Mejido, J. et al 2019)

Symptoms of Levator Ani Avulsion

A study conducted by Handa, V etal (2019) found that prolapse was significantly associated with levator ani avulsion. The study looked at 429 women across 5-10 years post birth. They were assessing for pelvic organ prolapse as a function of levator ani avulsion and levator hiatus size. They found that 25% of women had a prolapse and it was significantly associated with levator avulsion. (Handa, V. et al 2019). Women will often feel heaviness or bulging around the vagina and can struggle with leaking urine during certain activities.

Can I still have another baby after a Levator ani avulsion injury?

Horak, T etal 2014 conducted a retrospective analysis to see if there were any pelvic imaging changes between first and second births. Seven hundred and fifteen women participated in this study, of which 94 women had a second birth between the first and second post-partum follow up. There was an average of 2.7 years between deliveries. Of these 94 women, 71 had vaginal delivery. Findings after the second birth showed: increased bladder neck descent and no significant change to anterior prolapse descent.

This study found NO changes in 4D ultrasound findings in 87 participants. Meaning that they found no changes to Levator ani avulsion between first and second deliveries. The conclusion from this study was that “a second pregnancy and delivery does not seem to have a major effect of bladder support and/or Levator function”. The only case of worsening pelvic trauma out of the 94 women was a case in which they attempted a vaginal birth after caesarean (VBAC). This case was their first delivery was via caesarean with their second delivery being attempted via vaginal delivery. They concluded that more research needed to be completed to investigate pelvic trauma after VBAC.

Will a second pregnancy make my Levator avulsion worse?

A longitudinal study conducted by Chan, S et al 2017, looked at 666 women following their first delivery. These women were assessed for Levator ani avulsion at 8 weeks post-delivery and 3-5 years later. These women completed questionnaires and underwent a 3D trans labial ultrasound to assess them for avulsion. Three hundred and ninety-nine women completed this study, of these 151 had multiple births. Levator ani avulsion was seen in 69 women at 8 weeks post-delivery. Of these 69 women, 9 have no Levator ani avulsion at their 3-5 year follow up. It was not stated if these women had partial or complete levator ani avulsion or if they underwent surgical repair. One woman had a new Levator ani avulsion after her second vaginal delivery. This study concluded that the risk of developing a new levator ani avulsion after second vaginal delivery is 0.9%. Healing of levator ani avulsion was observed in 13% of women who had at least one vaginal delivery.  This study did not report on any treatment that the women had received during this study, only the ultrasound findings.

These articles will be attached to this blog post for you to read over as well. From these articles research indicates that those who have a levator ani avulsion you are at no greater risk of worsening it during your second birth. All cases are individual though and if you are concerned, I would always recommend speaking to your GP, midwife or women’s health physiotherapist. Education is power and the more you know about your body the more comfortable and confident you can be when giving birth. As always, the physiotherapists here at Bump Fitness are trained in Women’s Health and are here to offer you support and guidance during your pregnancy and for your pelvic health and wellbeing. Feel free to contact us at any time for an appointment to discuss your concerns!

Until next time,




  1. Chan SSC, Cheung RYK, Lee LL, Choy RKW, Chung TKH. Longitudinal follow-up of levator ani muscle avulsion: does a second delivery affect it? Ultrasound Obstet Gynecol. 2017 Jul;50(1):110-115. doi: 10.1002/uog.16009. Epub 2017 Jun 5. PMID: 27363589.https://pubmed.ncbi.nlm.nih.gov/27363589/
  2. Dietz, H.P., Moegni, F. and Shek, K.L. (2012), Diagnosis of levator avulsion injury: a comparison of three methods. Ultrasound Obstet Gynecol, 40: 693-698. https://doi.org/10.1002/uog.11190 https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.11190
  3. Handa VL, Roem J, Blomquist JL, Dietz HP, Muñoz A. Pelvic organ prolapse as a function of levator ani avulsion, hiatus size, and strength. Am J Obstet Gynecol. 2019 Jul;221(1):41.e1-41.e7. doi: 10.1016/j.ajog.2019.03.004. Epub 2019 Mar 15. PMID: 30885773; PMCID: PMC6592735.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6592735/
  4. Horak, Tracey & Guzmán Rojas, Rodrigo & Shek, Ka & Dietz, Hans. (2014). Pelvic Floor Trauma: Does the second baby matter?. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology. 44. 10.1002/uog.13252.https://www.researchgate.net/publication/259207375_Pelvic_Floor_Trauma_Does_the_second_baby_matter
  5. A. García-Mejido, C. Suarez-Serrano, E.M. Medrano-Sanchez, M.J. Bonomi Barby, A. Armijo Sánchez, J.A. Sainz. Pelvic floor rehabilitation in patients with levator ani muscle avulsion. Clin. Exp. Obstet. Gynecol.2020, 47(3), 341–347. https://doi.org/10.31083/j.ceog.2020.03.5252 https://www.imrpress.com/journal/CEOG/47/3/10.31083/j.ceog.2020.03.5252/htm
  6. Subramaniam, N., Eslick, G., Shek, K. and Dietz, H. (2019), P16.09: Obstetric risk factors for levator avulsion: a meta-analysis and systematic review. Ultrasound Obstet Gynecol, 54: 208-208. https://doi.org/10.1002/uog.21037 https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/uog.2103