Transcript Does cesarean section prevents from pelvic floor disorders
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%
Does cesarean section prevents from pelvic floor disorders ?
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/m 2 = 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 surgery Controls : 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 ?
Randomized controlled trial
[Hannah, Am J Obstet Gynecol, 2004]
Does cesarean section prevents from pelvic floor disorders ?
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-partum
Perineal pain Dyspareunia RR 0.32 [95% CI 0.1-0.5] RR 0.91 [95% CI 0.7-1.1]
At 2 years post-partum
Sexual dysfunction Perineal pain Unhappiness with sex RR 0.95 [95% CI 0.6-1.4] RR 0.65 [95% CI 0.3-1.1] RR 0.87 [95% CI 0.5-1.5] ** NS NS NS 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
Pregnancy itself plays a major role
Deffieux et al, 2010
12 wg 28 wg USI 36 wg UUI 3 M PP
Does cesarean section prevents from pelvic floor disorders ?
Cohort study
n=949 Short term follow-up
Does cesarean section prevents from pelvic floor disorders ?
Cohort study
n=949
Does cesarean section prevents from pelvic floor disorders ?
Prospective study
363 primiparous women
No difference
Does cesarean section prevents from pelvic floor disorders ?
Randomized controlled trial
[Hannah, Am J Obstet Gynecol, 2004]
Does cesarean section prevents from pelvic floor disorders ?
Long term follow-up…
Does cesarean section prevents from pelvic floor disorders ?
Iranian case controls study
Does cesarean section prevents from pelvic floor disorders ?
Mid-urethral slings (TVT) and pregnancy No randomized controlled trial Cases series
Literature 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 ?
Loss of bowel control can be devastating
Does cesarean section prevents from pelvic floor disorders ?
External anal sphincter injury (anal sphincter tear)
Anal sphincter injury during vaginal delivery
Sultan et al NEJM 1993
Does cesarean section prevents from pelvic floor disorders ?
Does caesarean section decreases the risk of fecal incontinence ?
Prospective study (nulliparous women)
[Chaliha, Am J Obstet Gynecol, 2001]
Fecal incontinence before pregnancy Fecal incontinence during pregnancy 2 % 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
Fecal incontinence Urinary incontinence Perineal pain Dyspareunia Vaginal delivery 0/I N=313 II III/IV N=671 N=81 8% 10% 4% 27% 15% 12% 7% 41% 19% 12% 7% 54% CS N=154 8% 5% 1% 29% 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 ?
120 100 80 60 40 20 0
9.4% 9.0% sphincter tear and incontinence no sphincter tear and incontinence sphincter tear no incontinence no sphincter tear no incontinence
25% CS 100% CS
250 C-section deliveries should be performed …to prevent one case of fecal incontinence related to anal sphincter injury
Does cesarean section prevents from pelvic floor disorders ?
Randomized controlled trial
[Hannah, Am J Obstet Gynecol, 2004]
Does cesarean section prevents from pelvic floor disorders ?
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]
2 years follow-up
Fecal incontinence RR 1.11 [95% CI 0.4-2.5] NS 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