Don't Forget the Pelvic Floor.

The pelvic floor is an important aspect of maternal morbidity that is too often neglected in the debate over vaginal versus cesarean deliveries. We have all seen the tremendous stretching and distension of a spontaneous vaginal delivery, but fewer of us see the long-term sequelae that this can cause in the pelvis.

Every obstetric unit knows its vaginal birth after cesarean (VBAC) rate and its primary and repeat section rate. Fewer units know their episiotomy rates or their third-and fourth-degree laceration rates. And I have yet to hear of a unit that can report on its urinary incontinence rate immediately postpartum, let alone later in life.

In the push from managed care parties as well as our own institutions and colleagues to decrease the cesarean section rate, we must consider the pelvic floor as we weigh the risks and benefits.

We should practice obstetrics with gynecology in mind, and practice gynecology with obstetrics in mind. This means broadening the window to look at a woman's entire lifespan and including in our plans her pelvic morbidity and the cost of treating urinary incontinence, pelvic organ prolapse, and fecal incontinence.

We also need to change our nomenclature and our attitudes about what constitutes a VBAC "success." Right now it simply means that the baby came out vaginally. I would submit to you that a 26-year-old who comes to my office with her uterus hanging half way down to her knees and wearing a diaper because she is incontinent of bowel and bladder is not a success. Perhaps a better way of thinking of it is in terms of completion.

And if a VBAC is not completed and the procedure has to be converted to a cesarean, that is not a failure any more than a change from a vaginal to an abdominal hysterectomy is a failure.

Serious pelvic floor damage is a high price to pay for a vaginal delivery. Although most vaginally parous women are free from pelvic symptoms, there is, indisputably, altered vaginal support, which in some cases can lead to ...