<p>It has long been known that vaginal birth can lead to structural pelvic floor damage. Using magnetic resonance imaging (MRI) and three-dimensional ultrasound defects of the levator ani muscle can be visualized and more extensive levator avulsions (detachment of the pubovisceral muscle from the inferior pubic ramus) can also be palpated. Levator avulsions are associated with pelvic floor problems, such as stress urinary incontinence, vaginal laxity, pelvic organ prolapse and increased risk of recurrence after pelvic floor surgery, sometimes with lifelong symptoms and severe impairment of the quality of life, including sexuality. Levator avulsions occur in 20–40% of vaginal births. Risk factors are forceps delivery (more than vacuum extraction), nulliparas &gt;35&#xa0;years, posterior occipital position, shoulder dystocia, birth weight &gt;4000 g, duration of the labor period and fundus pressure (Kristeller maneuver). If a&#xa0;mediolateral episiotomy is necessary, the incision should be made at least 60° from the midline to avoid anal sphincter damage. Further risk factors include obesity and smoking, positive family history and inability to contract pelvic floor muscles. So far there is no established treatment. Some avulsions seem to heal and pelvic floor muscle training did not show any additional improvement. Surgical treatment in the labor ward has not been investigated and also later there are still no convincing prospectively examined techniques, although case reports on transvaginal, laparoscopic or robot-assisted levator reconstruction have been published. As the treatment proves to be very difficult and the symptoms substantially impair the quality of life, prevention is paramount and needs to be established in antenatal clinics and labor wards.</p>