Women want to avoid pelvic floor injury: expert outlines risks, benefits of elective cesarean.(Obstetrics)

YOSEMITE, CALIF. -- One of the main reasons women may want a primary elective cesarian delivery is to protect the pelvic floor from injury leading to urinary and fecal incontinence, but they need to know that current evidence suggests it will not prevent every such case, Dr. Washington C. Hill said at a conference on obstetrics and gynecology sponsored by Symposia Medicus.

Regardless of whether physicians support the concept of primary elective cesarean, the practice has been established and the demand for it is likely to grow. Therefore, physicians need to be able to counsel women on the associated risks and benefits as specifically as possible given the current state of knowledge, said Dr. Hill, who is the director of maternal-fetal medicine at Sarasota (Fla.) Memorial Hospital.

"If you have not had someone ask you about this yet, you will," he said.

Dr. Hill reviewed the literature about those risks and benefits, for both the woman and the fetus.

The potential benefits to the woman include avoiding an emergency cesarean, with its potential complications, and avoiding the possibility of pudendal nerve injury if forceps must be used. The most important long-term benefit, however, is potential pelvic floor protection, Dr. Hill said.

Evidence suggests that pelvic floor disorders, specifically stress urinary incontinence, occur in about 25% of women post partum, but that most cases do not persist for more than 3 months. On the other hand, an estimated 11% of all women have at least one operation for pelvic organ prolapse or urinary incontinence during their lifetime.

The only study that prospectively evaluated stress urinary incontinence following planned cesarean versus vaginal delivery indicated that even with a planned cesarean--that is, no labor--incontinence still occurred in 5% of the women. The study was a survey taken 3 months post partum of 1,596 women who had singleton fetuses in a breech presentation at term. Seven percent of the women reported stress urinary incontinence after vaginal delivery (JAMA 287[14]:1822-31, 2002).