Elective C-Section Revisited.

The prophylactic use of elective cesarean section to prevent pelvic organ prolapse and urinary incontinence is gaining increased attention. Dr. W Benson Harer Jr., past president of the American College of Obstetricians and Gynecologists, stated publicly last year that women should have the right to choose a cesarean delivery

With some evidence from clinical experience, epidemiology, and pathophysiology to blame vaginal delivery for pelvic floor dysfunction, why shouldn't we offer prophylactic C-sections to prevent this problem later in life?

The answer is that the evidence does not support this approach. Preventive strategies should cause no more harm than the disease or problem that they are trying to prevent. Ideally, they should incorporate some kind of screening to identify people at risk. They should be cost effective and based on very good evidence of benefit. Elective C-section to preserve pelvic floor function fails on all these measures.

We don't know that elective cesarean is protective. The idea that this strategy just makes sense is hazardous, especially with invasive management. We also should keep in mind that most women who have vaginal deliveries don't develop incontinence or prolapse later in life.

The limited pathophysiologic evidence that elective C-section might decrease the risk of pelvic floor dysfunction rests on very small studies with very short follow-up times. Epidemiologic data suggest that a first vaginal delivery increases prolapse risk by about three- or fourfold and the risk of urinary incontinence by up to fivefold. The risk goes up with each additional vaginal delivery.

An elective C-section does not appear to eliminate this risk. Data suggest that women undergoing elective C-section have a two- or threefold higher risk for pelvic organ prolapse and incontinence compared with nulliparous patients.

Other factors could be promoting pelvic floor dysfunction besides delivery route. Consider that a recent study in Brazil, where many elective cesareans are performed, showed a 3.5-fold increased risk for urinary incontinence later in life after elective C-section, roughly equivalent to the rate after one vaginal delivery. In a study of more than 3,000 patients conducted in Australia, pelvic floor dysfunction was significantly associated with all modes of delivery