Elective (Primary) Cesarean
Section: Two Very Different
Viewpoints?
Kenneth Griffis, MD
Urogynecology & Reconstructive Pelvic Surgery
Introduction
• Discuss
– Elective cesarean section
– Pelvic floor disorders
• Vaginal delivery
Topics of Discussion
•
•
•
•
•
Pelvic organ prolapse
Urinary incontinence
Fecal incontinence
Legal
Ethical
4 Million Births Annually in the United States
The problem with
human childbirth:
A large object
must pass through
a constricted
channel with both
the object and the
channel emerging
unscathed...
Is There Structural
Damage?
Average peak
pressure during
Contraction
329 cm H2O
Rempen, J. Perinat Med
19(1991) 115-120
Vaginal wall, muscle, connective tissue, and nerve
stretch and tear
“It is thus evident that most of the damage
resulting from labor is due to injury, rupture,
distraction and displacement…” DeLee 1920
Pelvic floor tone & strength after vaginal delivery
Postpartum Anterior Vaginal Wall Prolapse
# of patients
40
30
41%
20
10
34%
25%
0
stage 0
stage 1
stage 2
Rest
Valsalva
Vaginal Delivery Associated with
Urethral Hypermobility
Fascial white line
Muscle white line
Pubovesical muscle
Pubocervical hammock
Rectovaginal septum
Rectal Prolapse
Anal
Sphincter
Lacerations
• 2 million vag del CA 1992-1997
• ASL = 5.85%
Handa OBG 2001
Anal Sphincter
Rectovaginal fistula
Postpartum Anal Sphincter
• Endoanal sonography
• 202 women in third tri, 150 6 weeks PP
• Sphincter defects
– 35% primips, 44% multips
• 0/23 with C/S had new defects
• 8/10 forceps had new defects
Sultan NEJM 1993
Pubococcygeal muscle injury
after first birth
•
•
•
•
•
•
80 primip stress incont women
80 primip continent women
9 mos after delivery
1 in 5 had visible damage to levator ani
90% involved pubococcygeus
Twice as many levator defects in stress
incontinent group as the controls
Delancey OBG 2003;101:46
Nerve Injury
Gilstrap Operative Obstetrics 2002
Neurophysiologic Evidence
• Denervation 42-80% of vag deliveries
• Not seen with C/S
• Denervation also seen in women with
SUI and AI
• May be cumulative with  parity
Pelvic Floor Dysfunction
and Parity
Prolapse by Vaginal Parity and
Stage in Women Seen for
Routine Care
70
60
%
2
1
50
2
40
1
30
20
10
0
1
0
2
3
Para 0
0
3
Para 1-3
0
3
Para >3
Swift AJOBG 2000
Parity, Prolapse & Stress Incontinence
Mant BJOBG 197;104:579
Rortveit NEJM 2003;348:900
10
Prolapse
8
6
4
Stress Urinary Incontinence
2
0
0
1
2
Parity
3
4+
UI 5 Yrs after Vaginal Delivery
Viktrup AJOBG 2001
100
80
%
N = 278
60
40
20
0
NO INCONT
1ST PREG
INCONT
1ST PREG
PERSISTENT
INCONT
1ST PREG
Urinary Incontinence After
Vaginal Delivery or Cesarean Section
30
25
%
20
Vaginal
15
C-Section
10
5
0
Para 1
Para 2
Para 3
Para 4
Rortveit NEJM 2003
Parity and Anorectal Function
• 144 women
• Age 45-58
• All vaginal deliveries
• Mean Parity = 2
• 10 yrs from delivery
Decreased Anorectal
function using 4
different measures
3
PNTML
2.8
2.6
2.4
2.2
2
0
1
2
3
4
Parity
Ryhammer Dis Colon Rectum 1996
AI 3 months after Delivery
7275 women
• Primips (n = 3261)
– Stool Incontinence 9.0%
– Flatal Incontinence 43.4%
– Forceps (OR 1.9)
– C/S (OR .58)
McCarthur BJOBG 2001
AI 3 months after Delivery
3261 primiparous women
AI Prevalence 9%
14
12
10
%
OR 1.9
8
6
4
2
OR 1
OR 1.3
ns
OR .58
0
C/S
SVD
Vacuum Forceps
McCarthur BJOBG 2001
Incidence of Anal Incontinence
after Anal Sphincter Laceration
• 11 Studies
• Europe & US
• 1988 – 1996
• Follow-up 3 – 78 mos
• n – 563
• Anal Incontinence
20 – 50% (mean 37%)
Episiotomy
• No proven benefits
• Associated with ASL
• Associated with Postpartum AI
• Associated with Postpartum Pain
Nulliparous 1st Vag Delivery PMH 1/88-12/00
Vaginal
N = 17,715
Spontaneous
N = 7140 (40%)
Epis
Forceps
N = 8083 (46%) N = 315 (2%)
Forceps + Epis
N = 2177 (12%)
ASL
ASL
ASL
ASL
N = 305 (4%)
N = 1590 (20%)
N = 85 (27%)
N = 1213 (55%)
ASL 2nd Delivery
5
P < 0.001

4
3
4.4%
2
1
0
1.3 %
NO ASL 1st Del
168/13328
ASL 1st Del
83/1895
What is Known
• Vag del causes anatomic injury
• Vag del consistent risk factor postpartum UI/AI
• ASL risk factor for postpartum AI
• Lifetime risk of UI/POP is high
• Vag Del is a risk factor for UI later in life
• Parity is a risk factor for POP later in life
What is Not Known
• Lifetime risk of AI
• Relationship between parity and AI
• Specific obstetrical risk factors
• The impact of other factors
• Why is PFD not more common
• Who will be affected
VAGINAL
DELIVERY
• •
UI, AI
POP
Pregnancy
NULLIP
AGE 20
•
•
RANDOMIZE
q 5 yrs
• •
C-SECTION
AGE 70
UI, AI
POP
Culture
 First world women are:
 more active
 less willing to accept pelvic floor problems
 Incontinence can destroy sport/recreation/job
satisfaction
 Culture of litigation (Western world)
 Lawsuits related to pelvic floor just a matter of
time
Statistics




10-60% of women report urinary incontinence
Objective studies - lower prevalence
50% of parous women develop prolapse
Only 10-20% seek medical care
Statistics
 Urinary incontinence
 10-25% of women age 15-64
 15-40% of women over age 60
 More than 50% of women in nursing homes
 W.H.O. recognizes incontinence as an
international health concern
Statistics
 Anal incontinence is the current greater
“pelvic floor closet issue”
 Incidence and prevalence figures vary
 Approximately 10% or more women with
urinary incontinence have incontinence of
flatus or stool
 Only 39% of anal incontinence after delivery
cleared in 10 months
 (MacArthur C,et al: BR J Obstet Gynaecol 104:46-50,1997)
Risk of C/S vs Vaginal
 Nonelective C/S rate > 27% might yield higher
maternal mortality than universal elective C/S
 Universal C/S - extra 1/18000 maternal
mortalities
 36 to 360 fetuses saved for each maternal
mortality related to elective C/S. (1/50 - 1/500
fetuses suffer disaster in utero after maturity)
 Feldman G.B, Freiman J.A; N Engl J Med 312, 1264-1267
Risk of Cesarean birth:
 Little data on purely elective C/S in healthy women
 Data usually include all C/S
 Sweden 1973-79: Mortality rate:
 emerg C/S: 0.18/1000
 elective C/S: 0.04/1000 (5:1)
 Other studies suggest smaller difference
 Risk C/S:vaginal 5:1 (not only elective!)
 We can probably do better
 heparin, universal A/B prophylaxis, etc.
 Lilford RJ et al; Br J Obstet 1990; 97:883-892
Cost of C/S vs vaginal birth:
 Depends on society (medical system)
 No level playing field in studies
 all C/S together
 Later prolapse/incontinence related costs
 not included
 direct & indirect
 Thus: most data biased
Lifetime Risk of Surgery for
UI or POP
11.1%
12
Incidence
10
7.5%
8
6
4.7%
4
2
2.8%
0.1%
0.9%
0
20-29
30-39
40-49
50-59
Age
60-69
70-79
Olsen OBG 1997
Surgery statistics (US)





Ratio of surgery for prolapse vs incontinence: 2:1
Lifetime risk of surgery for prolapse: 11.1%
Estimated re-operative rate: 29%
1/2 million prolapse surgeries /year (US)
2030 estimation: 7 mil/y + 2 mil reoperations
(Bump R, Norton P: OB/Gyn Clinics 25, # 4, Dec. 1998)
(Mailet VT et al: Presentation to AUGS, Sep 1997)
Legal Issues
• Informed consent?
• Future Lawsuits?
• Insurance fraud?
Informed Consent




Culturally based
Difficult and time consuming
NOT appropriate in labor
Taking into consideration
 fertility wishes and age
 37 yo wanting 1; vs 20 yo wanting 4
 Full discussion of relative risks, pros/cons
 Financial/resource issues - patient/society
Ethical
• Failure to inform?
– MSAFP for NTD 1:1000
– Genetic Screening 1:300
• Failure to provide care?
• Insurance fraud?
Elective cesarean birth for some
women?
“On the basis of current available evidence, the
concept of an elective prophylactic cesarean section
being outrageous, has been shattered by the fact that
almost a third of female obstetricians would choose it
for themselves”
Paterson-Brown S; Queen Charlotte’s and Chelsea Hospital, London.
Lancet 1996,347:544
Prevention of Childbirth Injuries
to the Pelvic Floor
Heit et al. Current Women’s Health Reports 2001
“Elective c/s for all pregnant women may not be as
unrealistic as it sounds……17% of obstetricians chose
elective c/s for themselves or their partners in the absence of
any clinical indication….Consumer demand could
contribute to rising c/s rates because women envision
greater freedom of choice….These choices are not based on
a knowledge deficit because 1/3 of the most knowledgeable
patients (female Ob/Gyn’s) would choose elective c/s for
themselves.”
Future of Pelvic Floor Dysfunction
Elective C/S for every pregnancy No!
Identification of Risk Factors Yes!
Prevention Yes!
Future of Pelvic Floor Dysfunction
Elective C/S for some pregnancies Yes!
after informed consent
Antenatal risk counselling
Prevention Yes!
Yes!