Is There an Underrecognized Connection?

By Jennifer Richards, LMT, NCBTMB Approved Provider

Disclaimer

This article is intended for educational purposes only and should not be interpreted as medical advice. It summarizes current scientific literature regarding hypermobile Ehlers-Danlos syndrome (hEDS), hypermobility spectrum disorders (HSD), childbirth, and pelvic floor dysfunction, while also presenting clearly identified hypotheses based on clinical observations and personal experience.

Where evidence exists, it is cited. Where evidence is limited, speculation is identified as such.

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Childbirth Is More Than Delivering a Baby

When we think about childbirth, we often focus on labor and delivery. Yet birth represents one of the greatest physiological challenges the human body will ever experience.

Successful childbirth requires coordinated function of:

• Connective tissues
• Pelvic floor muscles
• Peripheral nerves
• The autonomic nervous system
• Hormonal signaling
• The cardiovascular system
• The immune system

Recovery requires all of these systems to heal—not simply the uterus.

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What We Know

Research consistently demonstrates that individuals with hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD) experience higher rates of:

• Pelvic organ prolapse
• Urinary incontinence
• Chronic pelvic pain
• Joint instability
• Connective tissue fragility
• Delayed wound healing

Collagen abnormalities likely contribute to decreased tensile strength of ligaments, fascia, skin, and pelvic support structures.

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Perineal Tears

Perineal tears are common during vaginal delivery.

However, connective tissue disorders raise important questions:

Could tissues be more susceptible to:

• More extensive tearing?
• Delayed healing?
• Wound dehiscence?
• Persistent pain?
• Long-term pelvic floor dysfunction?

Although definitive research is limited, these questions are biologically plausible given what we know about collagen disorders.

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Obstetric Fistulas

A fistula is an abnormal connection between two organs, most commonly:

• Rectovaginal fistula
• Vesicovaginal fistula

These injuries can result in:

• Continuous leakage of urine or stool
• Recurrent infections
• Skin breakdown
• Significant emotional distress
• Multiple reconstructive surgeries

In high-income countries, fistulas most commonly occur after severe obstetric trauma, difficult deliveries, or surgical complications.

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What the Research Says

At present, there is insufficient evidence to conclude that hEDS directly increases the risk of obstetric fistulas.

However, there are strong biological reasons to investigate whether connective tissue disorders may contribute to:

• Increased tissue fragility
• More extensive obstetric injury
• Impaired healing
• Persistent pelvic floor dysfunction

This represents an important gap in current research.

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The Nervous System May Also Play a Role

Labor is not solely mechanical.

The autonomic nervous system regulates:

• Blood pressure
• Heart rate
• Pain perception
• Hormonal signaling
• Blood flow to healing tissues

Many individuals with hEDS experience dysautonomia, including POTS.

Whether autonomic dysfunction influences tissue recovery after childbirth remains largely unknown but deserves further investigation.

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My Clinical Question (Hypothesis)

The following section reflects my observations and should be interpreted as hypothesis rather than established fact.

During my career as a massage therapist, educator, and someone living with hypermobility, I have repeatedly encountered stories involving:

• Severe tearing during childbirth
• Difficult postpartum recovery
• Pelvic floor dysfunction
• Chronic pelvic pain
• Incontinence
• Obstetric fistulas
• Persistent exhaustion following delivery

My own childbirth experience included a severe tear, profound exhaustion, and an altered level of awareness during labor. Family members and close friends have also experienced significant childbirth-related pelvic injuries, including fistulas. These personal experiences do not establish a causal relationship, but they have prompted me to ask an important scientific question:

Could connective tissue disorders predispose some individuals not only to musculoskeletal complications, but also to more severe obstetric tissue injury and impaired postpartum healing?

Current research does not yet provide a definitive answer.

I hope future studies will.

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Why This Matters

Recognition of connective tissue disorders continues to grow.

Understanding how collagen disorders influence pregnancy and childbirth could improve:

• Prenatal counseling
• Labor positioning
• Tissue protection during delivery
• Postpartum rehabilitation
• Pelvic floor physical therapy referrals
• Long-term quality of life

Many women have been told their postpartum symptoms are simply “part of having children.”

For some, they may represent the lasting consequences of an underlying connective tissue disorder.

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Final Thoughts

Science advances because clinicians, researchers, and patients ask thoughtful questions.

Not every observation becomes a proven theory.

But every important discovery begins with someone asking:

“Could there be a connection we have not yet recognized?”

I believe childbirth in connective tissue disorders deserves that question.

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Selected References

• Castori M. Ehlers-Danlos Syndrome, Hypermobility Type: An Underrecognized Heritable Disorder With Mucocutaneous, Articular, and Systemic Manifestations. ISRN Dermatology. 2012.
• The Ehlers-Danlos Society. Management and Care Guidelines for hEDS/HSD.
• Hakim AJ, Grahame R, et al. Research on hypermobility spectrum disorders and Ehlers-Danlos syndrome.
• International Continence Society. Resources on pelvic floor dysfunction and childbirth.
• American College of Obstetricians and Gynecologists. Guidance on obstetric lacerations and postpartum care.