Although it is well-known that parous women have excess risk for pelvic floor disorders, including prolapse and incontinence, the role played by mode of delivery has been uncertain.
In a recent report from the journal Obstetrics and Gynecology, investigators evaluated more than 1000 women, who delivered 5-10 years earlier, for symptoms of pelvic floor disorders and evidence of prolapse on pelvic examination. At enrollment, median age was 40 years, and almost three fourths of the women were multiparous.
Stress urinary and anal incontinence were each reported by 11% of women. Although prolapse was noted in 7% of women, only 3% reported that they were bothered by symptoms. Compared with cesarean without labor, spontaneous and operative vaginal birth were associated with 6- to 8-fold higher risks of prolapse and 3- to 4-fold higher risks of stress urinary incontinence. The likelihood of developing pelvic floor disorders was similar among all women who had delivered by cesarean, regardless of whether labor occurred before delivery.
This report clarifies that vaginal birth, particularly when vacuum- or forceps-assisted, is associated with substantially higher risk for pelvic floor disorders. However, other points should be considered before rushing to the conclusion that elective cesarean to protect the pelvic floor should become routine. Most women with prolapse discovered on examination have few if any symptoms. Furthermore, multiple cesarean deliveries are associated with important morbidities including placenta accreta. Finally, pelvic floor disorders that occur shortly after delivery often improve on their own over time.
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