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Jan 24

Cesarean on Demand Does Not Eliminate Risk of Prolapse

Worldwide, “cesarean on demand” continues to increase. In the hopes of avoiding pelvic floor damage associated with birthing, some women have bought into the the trend for elective cesarean before onset of labor. Called “cesarean on demand” because patients demand it in the absence of a maternal or fetal indication, it’s the obstetric equivalent of Erica Jong’s “Zipless F**k”; the maternity version of having your cake and eating it too.

Well, guess what? Just BEING PREGNANT is a risk for all the unhappiness that pelvic floor mayhem can bring, including incontinence and its painfully un-sexy cousin, pelvic organ prolapse. One beautifully executed study evaluated vaginal anatomy before and after 1st pregnancy in three groups of mothers; one who had an easy vaginal birth, another who had a difficult vaginal birth with deep vaginal tearing that required lots of stitching, and third who, whatever the reason, had cesarean before going into labor. Understand that there are medically legitimate reasons for a woman to have cesarean without labor, such as toxemia (pregnancy induced high blood pressure), placenta previa (low-lying placenta blocking the cervix – natural labor with this condition results in the baby bleeding to death before it can be born), or breech presentation (at least in the States, due to out of control obstetric malpractice and the fact that breeches born vaginally have a small but real risk of birth injury that can be almost totally avoided with a cesarean, breech = cesarean until further notice), to name a few.

Looking at the pelvic floor support of these women after first birth, they found NO DIFFERENCE in moderate prolapse between the three groups. Severe prolapse was equivalent in the two vaginal birth groups and much higher than in the cesarean without labor group. But… the cesarean without labor group had a 5% incidence of severe prolapse – I’m talking cervix sticking out of the vagina prolapse, bladder bulging down pushing the labia apart when you walk prolapse.  Thinking a cesarean is the answer to your “I want to be a mother but I don’t want any physical changes in my body anywhere, especially in my vagina” dreams? Think again…

Here’s the study summary prepared for the Journal of Sexual Medicine:

Handa VL, Nygaard I, Kenton K, Cundiff GW, Ghetti C, Ye W, Richter HE. Pelvic organ support among women in the first year after childbirth. Int Urogynecol J (2009)1407-1411.

Increased public awareness of changes in pelvic floor anatomy related to pregnancy continues to foster the growing phenomenon of cesarean on demand, requested in the hopes of maintaining pre-pregnancy sexual function and reducing risk of prolapse and incontinence, two conditions known to negatively impact sexual quality of life in the majority of women so-affected. The true impact of pregnancy on pelvic support may be due to pregnancy itself, regardless of delivery mode, as stated by these authors; “cesarean delivery as a potential prevention strategy remains unproven.” This study prospectively evaluated the impact of first pregnancy on pelvic organ support of 256 women with three pregnancy outcomes – vaginal delivery without anal sphincter tear, vaginal delivery with anal sphincter tear, and cesarean delivery without labor. Pelvic support evaluation done at 6-12 month post-delivery showed stage 2 prolapse in 38% of women delivered vaginally with sphincter tear, 29% in those delivered vaginally without sphincter tear, and in 21% of women delivered by no-labor cesarean with no statistically significant differences between groups.  It is remarkable that 1/5 of the cesarean patients showed clinically significant stage 2 prolapse.  When looking further at stage 3 (true bulging past the hymen, clearly visible and palpable through the vaginal opening), there was a significant difference between vaginal birth and cesarean without labor, with 5% of cesarean women showing visible prolapse as opposed to 14-15% in both of the vaginal delivery groups.  Still, this 5% bulging prolapse despite non-labor cesarean raises the possibility that optimal patient counseling for women seeking elective cesarean for sexual function and pelvic organ protection may best include the realistic prediction of “a small but real risk bad prolapse even if you undergo cesarean before going into labor”. Letting women know that cesarean is NOT a 100% guarantee of avoiding pelvic floor consequences of pregnancy, along with the other risks of cesarean: peri-op morbidity, increased risk of placenta accreta, and increased risk of uterine rupture with subsequent pregnancies. This work adds to the data revealing that the impact of pregnancy on the pelvic floor may not be thoroughly negated by cesarean on demand.

Level of Evidence: IA

2 pings

  1. Tweets that mention Cesarean on Demand Does Not Eliminate Risk of Prolapse | Dr. Romanzi -- Topsy.com

    [...] This post was mentioned on Twitter by Kim Vopni, DrRomanzi. DrRomanzi said: Cesarean-on-demand does not eliminate risk of pelvic organ prolapse. Wanna make babies? Get real about the risks: http://tinyurl.com/683x2l8 [...]

  2. BEDSIDE MANNERS: Peeing When You Laugh is Not Funny, Neither is Misrepresenting Research | Girl with Pen

    [...] partner forwarded me a recent blog post on a board-certified urogynecologist’s website titled “Cesarean on Demand Does Not Eliminate Risk of Prolapse.”  This post highlights the findings of a 2009 research article published in the International [...]

    Says Dr, R:
    This is an interesting academic critique of my blogpost, accusatory in nature, and bit confused in it’s title that alludes to incontinence while lambasting a blogpost on a scientific study on prolapse. Perhaps the author is drawing unsubstantiated conclusions about data not covered in this study, which did evaluate prolapse but did not evaluate or report on urinary continence or incontinence in this group of women. While incontinence and prolapse often occur in the same woman, they also often occur in isolation. Many women with prolapse suffer no incontinence, and many an horrifically incontinent woman suffers nary a speck of prolapse whatever.

    I enjoyed reading this critique, and encourage my blog followers to do likewise. It’s an interesting glimpse into the back-story of how research is scrutinized. Claiming that I misrepresented published medical data, this scientist parses the original manuscript like a seasoned editorial veteran, drawing conclusions about my conclusions that are neither right nor wrong, well-honed though they may be.

    Suffice it to say, 5% of women in the “cesarean-no labor” group in this study demonstrated severe, grade 3 prolapse after birthing their first child. Women hoping to completely avoid pelvic support damage need to know that while cesarean reduces the risk, as clearly demonstrated in this paper, it does not guarantee it. The fact that the authors were not 100% certain that the women did not prolapse before or during pregnancy does not detract from the fact that women who underwent cesarean without labor came out of that first pregnancy with horrific prolapse. Cesarean did not guarantee prevention of moderate or severe prolapse for the women evaluated in this study. It did make severe prolapse far less likely, but it did not correlate to an complete absence of prolapse for the women evaluated in this manuscript, regardless the imperfections (and all scientific manuscripts contain imperfections) of the methods.

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