Does cesarean section prevents from pelvic floor disorders ?

Xavier Deffieux (MD, PhD)

Gynecologic Surgery, Antoine Beclere Hospital, Clamart

University of Paris (France)

Tehrān, 2010

Does cesarean section prevents from pelvic floor disorders ?

Does cesarean section prevents from pelvic floor disorders ?

China 2010 50%

India 18%

WHO (World Health Organization) “A C-section > 15% indicates that too many unnecessary C-sections are being performed”

Does cesarean section prevents from pelvic floor disorders ?

China 2010 50%

India 18%

Caesarean section raises the risk of complications for the mother

The cost of C-section is higher than natural birth

Does cesarean section prevents from pelvic floor disorders ?

Why so many elective C sections in the world ?

China 2010 50%

India 18%

When asked why women prefer C-section

… almost all recounted problems with :

- fetal distress and mortality

- excessive pain

- trauma to the vagina and potential pelvic floor

disorders

(urinary incontinence, fecal incontinence,

dyspareunia…)

It is important for every woman to understand what she can do to

protect her pelvic floor and avoid pelvic floor disorders

Informed consent is required before choice of delivery mode

Obstetricians and gynecologists must inform women concerning

this point

Does cesarean section prevents from pelvic floor disorders ?

Thus…the question is

« Does caesarean section prevents from pelvic floor

disorders ? »

Urinary and fecal incontinence, POP, sexual dysfunction

Hypothesis :

- Vaginal delivery is the etiology of pelvic floor dysfunction

- Caesarean section (Cs) avoid vaginal delivery

- Conclusion : Cs prevents from pelvic floor dysfunction

First point…

Vaginal delivery is not the unique etiology of pelvic floor

dysfunction

BMI > 30 g/m2 = risk factor of urinary incontinence at long term

follow-up [Fritel,

BJOG, 2005]

Does cesarean section prevents from pelvic floor disorders ?

Does caesarean section prevents

from pelvic organ prolapse and sexual

dysfunction ?

Does cesarean section prevents from pelvic floor disorders ?

Does C-section prevents from POP surgery ?

Case controls study (7556 primiparous women)Case : women who have undergone POP surgeryControls : women who did not

Does cesarean section prevents from pelvic floor disorders ?

Does C-section prevents from sexual dysfunction ?

[Klein, J Obstet Gyaecol Can, 2005]

Prospective cohort study

C-section (n=135) vaginal delivery (n=864)

At 3 months follow-up following delivery

Unhappy with sexual relations :

- 54% following C-section

- 70% following vaginal delivery p<0.05

…however, no difference in dyspareunia rates(31% vs

31%)

Does cesarean section prevents from pelvic floor disorders ?

Does cesarean section prevents from pelvic floor disorders ?

Randomized controlled

trial [Hannah, Am J Obstet Gynecol, 2004]

Does C-section prevents from sexual

dysfunction ?

Cochrane Database

Meta-analysis

Elective C-section vs vaginal delivery

3 studies (n=2396)

At 3 months post-partumPerineal pain RR 0.32 [95% CI 0.1-0.5]

**Dyspareunia RR 0.91 [95% CI 0.7-1.1] NS

At 2 years post-partumSexual dysfunction RR 0.95 [95% CI 0.6-1.4]

NSPerineal pain RR 0.65 [95% CI 0.3-1.1] NSUnhappiness with sex RR 0.87 [95% CI 0.5-1.5]

NS

Does cesarean section prevents from pelvic floor disorders ?

Does caesarean section decreases the risk of urinary incontinence ?

Does cesarean section prevents from pelvic floor disorders ?

Caesarean section is unable to prevent all urinary incontinence because vaginal delivery

is not the only etiology of urinary incontinence

Does cesarean section prevents from pelvic floor disorders ?

Deffieux et al, 2010

Pregnancy itself plays a major role

12 wg 28 wg 36 wg 3 M PP

Pre

vale

nce

of

uri

nary

sym

tpom

s

USI UUI

Cohort studyn=949

Does cesarean section prevents from pelvic floor disorders ?

Short term follow-up

Does cesarean section prevents from pelvic floor disorders ?

Cohort studyn=949

Prospective study

363 primiparous women

Does cesarean section prevents from pelvic floor disorders ?

No difference

Does cesarean section prevents from pelvic floor disorders ?

Randomized controlled

trial [Hannah, Am J Obstet Gynecol, 2004]

Long term follow-up…

Does cesarean section prevents from pelvic floor disorders ?

Does cesarean section prevents from pelvic floor disorders ?

Iranian case controls study

Mid-urethral slings (TVT) and pregnancy

No randomized controlled trial

Cases seriesLiterature review : 29 case reports

Recurrence rate of urinary incontinence

- 3 (21 %) following C section

- 4 (26 %) following vaginal delivery …no

difference

C-section is not recommended in pregnant women with TVT

Does cesarean section prevents from pelvic floor disorders ?

Does caesarean section decreases the risk

of fecal incontinence ?

Does cesarean section prevents from pelvic floor disorders ?

Does cesarean section prevents from pelvic floor disorders ?

Loss of bowel control can be devastating

External anal sphincter injury (anal sphincter tear)

Does cesarean section prevents from pelvic floor disorders ?

Anal sphincter injury during vaginal delivery

Sultan et al NEJM 1993

Does caesarean section decreases the risk of fecal incontinence ?

Prospective study (nulliparous women)[Chaliha, Am J Obstet Gynecol, 2001]

Fecal incontinence before pregnancy 2 %Fecal incontinence during pregnancy 15 %

Among women presenting with fecal incontinence

… 45% do not present any anal sphincter injury

Does cesarean section prevents from pelvic floor disorders ?

PRIMA study 1219 primiparous women

Faltain et al. Obstet Gynecol 2005

0/I II III/IV CS N=313

N=671 N=81 N=154

Fecal incontinence 8% 15% 19% 8% Urinary incontinence 10% 12% 12% 5% Perineal pain 4% 7% 7% 1% Dyspareunia 27% 41% 54% 29%

Ana

l sph

inct

er te

ar

Cae

sare

an s

ecti

on

Vaginal delivery

Does cesarean section prevents from pelvic floor disorders ?

The prevalence of fecal incontinence is not different

following normal vaginal delivery and C-section

Does cesarean section prevents from pelvic floor disorders ?

100% cesarean sections: a solution ?

0

20

40

60

80

100

120

25% CS 100% CS

sphincter tear andincontinence

no sphincter tear andincontinence

sphincter tear noincontinence

no sphincter tear noincontinence

250 C-section deliveries should be performed

…to prevent one case of fecal incontinence related to anal sphincter injury

9.4% 9.0%

Does cesarean section prevents from pelvic floor disorders ?

Randomized controlled

trial [Hannah, Am J Obstet Gynecol, 2004]

Does caesarean section decreases the risk of fecal incontinence ?

Cochrane Database

Meta-analyse

Elective C-section vs VB

3 studies(n=2396)

3 months follow-up afterdelivery

Fecal incontinence RR 0.54 [95% CI 0.1-1.6]

NS

2 years follow-up

Fecal incontinence RR 1.11 [95% CI 0.4-2.5]

NS

Does cesarean section prevents from pelvic floor disorders ?

Conclusion

Elective C-section (with no trial of labour) is associated

with a lower prevalence of post-partum urinary

incontinence (at 3 months FU)

However…

C-section do not prevents from long term urinary or fecal

incontinence

C-section do not prevents from long term sexual disorders

Does cesarean section prevents from pelvic floor disorders ?

Conclusion

Scientific data is insufficient to justify an elective

cesarean section in order to avoid pelvic floor

symptoms

Does cesarean section prevents from pelvic floor disorders ?

Conclusion

Further studies are required in high risk women

- women with previous pelvic floor disorders

- age > 40 years old

Does cesarean section prevents from pelvic floor disorders ?