Elective (Primary) Cesarean Section: Two

Very Different Viewpoints?

Kenneth Griffis, MDUrogynecology & 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...

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 Is There Structural Damage?Damage?

Average peak Average peak pressure during pressure during

ContractionContraction329 cm H2O329 cm H2O

Rempen, J. Perinat Med Rempen, J. Perinat Med 19(1991) 115-12019(1991) 115-120

Vaginal wall, muscle, connective tissue, and nerve Vaginal wall, muscle, connective tissue, and nerve stretch and tearstretch and tear

““It is thus evident that most of the damage It is thus evident that most of the damage resulting from labor is due to injury, rupture, resulting from labor is due to injury, rupture,

distraction and displacement…” distraction and displacement…” DeLee 1920DeLee 1920

Pelvic floor tone & strength after vaginal delivery

Postpartum Anterior Vaginal Wall Prolapse

00

1010

2020

3030

4040

stage 0stage 0 stage 1stage 1 stage 2stage 2

# o

f p

atie

nts

# o

f p

atie

nts

25%25%

34%34%

41%41%

Rest ValsalvaRest Valsalva

Vaginal Delivery Associated with Urethral Hypermobility

Fascial white line

Pubocervical hammock

Pubovesical muscle

Muscle white line

Rectovaginal septum

Rectal Prolapse

Anal

Sphincter

Lacerations

• 2 million vag del CA 1992-19972 million vag del CA 1992-1997

• ASL = ASL = 5.85%5.85%

Handa OBG 2001Handa OBG 2001

Anal SphincterAnal Sphincter

Rectovaginal fistula

Postpartum Anal Sphincter

• Endoanal sonographyEndoanal sonography

• 202 women in third tri, 150 6 weeks PP202 women in third tri, 150 6 weeks PP

• Sphincter defects Sphincter defects

– 35% primips, 44% multips35% primips, 44% multips

• 0/23 with C/S had new defects0/23 with C/S had new defects

• 8/10 forceps had new defects8/10 forceps had new defectsSultan NEJM 1993Sultan NEJM 1993

Pubococcygeal muscle injury after first birth

• 80 primip stress incont women80 primip stress incont women

• 80 primip continent women80 primip continent women

• 9 mos after delivery9 mos after delivery

• 1 in 5 had visible damage to levator ani 1 in 5 had visible damage to levator ani

• 90% involved pubococcygeus90% involved pubococcygeus

• Twice as many levator defects in stress Twice as many levator defects in stress incontinent group as the controlsincontinent group as the controls

Delancey OBG 2003;101:46

Gilstrap Operative Obstetrics 2002

Nerve InjuryNerve Injury

Neurophysiologic Evidence

• Denervation 42-80% of vag deliveries Denervation 42-80% of vag deliveries

• Not seen with C/SNot seen with C/S

• Denervation also seen in women with Denervation also seen in women with

SUI and AI SUI and AI

• May be cumulative with May be cumulative with parityparity

Pelvic Floor Dysfunction Pelvic Floor Dysfunction

and Parityand Parity

0

10

20

30

40

50

60

70

Para 0Para 0 Para 1-3Para 1-3 Para >3Para >3

Prolapse by Vaginal Parity and Stage in Women Seen for

Routine Care

%%

Swift AJOBG 2000Swift AJOBG 2000

00

11

2233

00 00

11

11

22

22

33 33

Parity, Prolapse & Stress Incontinence

0

2

4

6

8

10

0 1 2 3 4+

Prolapse

Stress Urinary Incontinence

Parity

Rela

tive R

i sk

Mant BJOBG 197;104:579Rortveit NEJM 2003;348:900

UI 5 Yrs after Vaginal DeliveryUI 5 Yrs after Vaginal Delivery

0

20

40

60

80

100

NO INCONT1ST PREG

INCONT1ST PREG

PERSISTENTPERSISTENTINCONTINCONT

11ST PREG PREG

%%

Viktrup AJOBG 2001

N = 278

Urinary Incontinence AfterUrinary Incontinence AfterVaginal Delivery or Cesarean Section Vaginal Delivery or Cesarean Section

0

5

10

15

20

25

30

Para 1 Para 2 Para 3 Para 4

Vaginal

C-Section

%%

Rortveit NEJM 2003Rortveit NEJM 2003

Parity and Anorectal FunctionParity and Anorectal Function

2

2.2

2.4

2.6

2.8

3

0 1 2 3 4

Parity

mse

c

PNTMLPNTML• 144 women144 women• Age 45-58Age 45-58• All vaginal deliveriesAll vaginal deliveries• Mean Parity = 2Mean Parity = 2• 10 yrs from delivery10 yrs from delivery

Ryhammer Dis Colon Rectum 1996Ryhammer Dis Colon Rectum 1996

Decreased Anorectal Decreased Anorectal

function using 4 function using 4

different measuresdifferent measures

AI 3 months after Delivery7275 women

McCarthur BJOBG 2001

• Primips (n = 3261)

– Stool Incontinence 9.0%

– Flatal Incontinence 43.4%

– Forceps (OR 1.9)

– C/S (OR .58)

AI 3 months after Delivery3261 primiparous women

00

22

44

66

88

1010

1212

1414

C/S SVD Vacuum Forceps

%%OR 1OR 1

OR .58OR .58

OR 1.3OR 1.3nsns

OR 1.9OR 1.9

AI Prevalence 9%

McCarthur BJOBG 2001

Incidence of Anal Incontinence Incidence of Anal Incontinence after Anal Sphincter Lacerationafter Anal Sphincter Laceration

• 11 Studies11 Studies

• Europe & USEurope & US

• 1988 – 19961988 – 1996

• Follow-up 3 – 78 mosFollow-up 3 – 78 mos

• n – 563n – 563

• Anal IncontinenceAnal Incontinence

20 – 50% (mean 37%)20 – 50% (mean 37%)

Episiotomy

• No proven benefitsNo proven benefits

• Associated with ASLAssociated with ASL

• Associated with Postpartum AIAssociated with Postpartum AI

• Associated with Postpartum PainAssociated with Postpartum Pain

Nulliparous 1Nulliparous 1stst Vag Delivery PMH 1/88-12/00 Vag Delivery PMH 1/88-12/00

VaginalVaginalN = 17,715N = 17,715

VaginalVaginalN = 17,715N = 17,715

SpontaneousSpontaneousN = 7140 (40%)N = 7140 (40%)

SpontaneousSpontaneousN = 7140 (40%)N = 7140 (40%)

EpisEpisN = 8083 (46%)N = 8083 (46%)

EpisEpisN = 8083 (46%)N = 8083 (46%)

ForcepsForcepsN = 315 (2%)N = 315 (2%)

ForcepsForcepsN = 315 (2%)N = 315 (2%)

Forceps + EpisForceps + EpisN = 2177 (12%)N = 2177 (12%)

Forceps + EpisForceps + EpisN = 2177 (12%)N = 2177 (12%)

ASLASLN = 305 N = 305 (4%)(4%)

ASLASLN = 305 N = 305 (4%)(4%)

ASLASLN = 1590 N = 1590 (20%)(20%)

ASLASLN = 1590 N = 1590 (20%)(20%)

ASLASLN = 85 N = 85 (27%)(27%)

ASLASLN = 85 N = 85 (27%)(27%)

ASLASLN = 1213 N = 1213 (55%)(55%)

ASLASLN = 1213 N = 1213 (55%)(55%)

ASL 2ASL 2ndnd Delivery Delivery

0

1

2

3

4

5

1.3 %1.3 %

4.4%4.4%

168/13328168/13328 83/189583/1895

P < 0.001

NO ASL 1NO ASL 1stst Del Del ASL 1ASL 1stst Del Del

%%

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 Lifetime risk of AI

• Relationship between parity and AIRelationship between parity and AI

• Specific obstetrical risk factorsSpecific obstetrical risk factors

• The impact of other factorsThe impact of other factors

• Why is PFD not more commonWhy is PFD not more common

• Who will be affectedWho will be affected

UI, AIPOP

UI, AIPOP

NULLIPNULLIPAGE 20AGE 20

q 5 yrsq 5 yrs AGE 70AGE 70

VAGINALVAGINALDELIVERYDELIVERY

C-SECTIONC-SECTION

PregnancyPregnancy

RANDOMIZE•

•

•

•

•

•

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

0

2

4

6

8

10

12

20-29 30-39 40-49 50-59 60-69 70-79

AgeAge

Incid

en

ce

Incid

en

ce

0.1%0.1%0.9%0.9%

2.8%2.8%

4.7%4.7%

7.5%7.5%

11.1%11.1%

Olsen OBG 1997Olsen 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 Elective C/S for every pregnancy

Prevention Prevention

Identification of Risk FactorsIdentification of Risk Factors

No!No!

Yes!Yes!

Yes!Yes!

Future of Pelvic Floor Dysfunction

Elective C/S for some pregnanciesElective C/S for some pregnancies after informed consent after informed consent

Prevention Prevention

Antenatal risk counsellingAntenatal risk counselling

Yes!Yes!

Yes!Yes!

Yes!Yes!