Urinary Incontinence: Is Cesarean Delivery Protective?
Section snippets
Factors Important in Framing this Discussion
In evaluating the literature about cesarean delivery and UI, several points are important to consider. Comparing outcomes between vaginal delivery and cesarean delivery is NOT the same as comparing outcomes between planned vaginal and planned cesarean deliveries. Currently, 30% of planned vaginal deliveries in the U.S. result in cesarean deliveries instead. A cesarean delivery conducted after the onset of labor, and in particular, after the onset of the second stage of labor, may have a
UI During and After Delivery
Nulligravid pregnant women leak more often than nulliparous counterparts.3 Indeed, numerous studies reveal that 15% to 65% of women report UI symptoms during and shortly after pregnancy (Table 1). Thus, pregnancy itself causes UI, transient in some but lasting in others.
This is relevant, because antepartum UI increases the risk for postpartum UI. For example, Foldspang followed 1232 women 12 to 120 months postpartum.4 Of the 16% that had antenatal UI, 67% reported postpartum UI, compared with
Cesarean Delivery and Postpartum UI
The best data to inform the discussion about cesarean delivery on request is that which separates out cesarean deliveries done before and after the onset of labor. However, given the dearth of such information, data on cesarean deliveries in general will also be reviewed to provide the reader with as broad a picture as possible. Several prospective studies evaluated the risk of postpartum UI by delivery type, grouping all cesarean deliveries together. In 3405 primiparas 3 months postpartum,
Cesarean Delivery and UI After Multiple Deliveries
The studies described above generally assessed UI outcome after one delivery. Although these data are important, they do not reflect the reality of childbearing in the U.S. Scant data evaluates risk prospectively after more than one delivery. Foldspang initially evaluated women postpartum after one delivery and found a marked decrease in UI after cesarean delivery (all types) than after vaginal delivery (12% versus 28%, respectively).4 However, in 642 women that had a second delivery, cesarean
Cross-Sectional Studies
In addition to cohort studies, there are cross-sectional studies that address the difference in UI based on delivery type. These studies generally evaluate women more remote from delivery and thus include middle-aged or older women, rather than young postpartum women. In these studies, there are often no differences in UI prevalence by delivery type. In 2625 women ages 49 to 61 years, 15% had severe UI (“often/all the time”).20 Nulliparous women had a lower prevalence of severe UI (7%), but
Cesarean Delivery and the Risk of Future Surgery
Data are mixed about whether cesarean deliveries impact the risk of future surgeries for urinary incontinence or pelvic organ prolapse. Most studies group both conditions together, and most do not differentiate between types of cesarean. In a nested case-control study in which an historical cohort was linked with a current morbidity database, women who first delivered between 1952 and 1966 were evaluated.24 Cases included 352 women that had surgery for UI or pelvic organ prolapse; this group
Sister Studies
Studies comparing sisters aim to evaluate the role of delivery type in UI prevalence, controlling for potential genetic contributions. Although one study of older sisters (mean age 61 years) does not specifically address the issue of cesarean delivery, the results speak to the impact of childbirth on UI.29 In this study, 143 postmenopausal sister pairs were enrolled; one sister was nulliparous and one parous. The prevalence of UI was the same in both groups: 47.6% in nulliparous and 49.75 in
Randomized Trial
Only one randomized trial has assessed the difference in pelvic floor symptoms after planned elective cesarean delivery or planned vaginal birth: the Term Breech Trial.31 Questionnaires were completed 3 months postpartum by 1596 women from 110 centers around the world. Three months postpartum, women in the planned cesarean delivery group reported less UI than those in the planned vaginal birth group (4.5% versus 7.3%; RR 0.62, 95% CI 0.41-0.93). Other outcomes did not differ. However, by 2
Conclusion
The following key points summarize current knowledge about the role of cesarean delivery on UI:
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Vaginal delivery increases the short-term risk of UI in young and middle-aged women more than cesarean delivery.
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Most women with UI have mild incontinence.
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Nulliparous women also develop UI.
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Mode of delivery no longer plays a role in the development of UI in older women; older nulliparous women are as likely to have UI as older parous women.33
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Nearly eight in nine women deliver babies, usually via the
Acknowledgments
This work is supported in part by K24 HD42469-01 from the National Institutes of Child Health and Human Development. The sponsor had no role in data collection, data analysis, data interpretation, or in the writing of the report.
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Cited by (34)
Caesarean section on maternal request for non-medical reasons: Putting the UK National Institute of Health and Clinical Excellence guidelines in perspective
2013, Best Practice and Research: Clinical Obstetrics and GynaecologyCitation Excerpt :On the other hand, caesarean section may reduce the incidence of SUI, but cohort studies and meta-analyses differ significantly in estimating the numbers of caesarean section needed to prevent one case of SUI.68 Again, the protective effect of a caesarean section decreases with age, dissipates with future vaginal births,69 and is abolished after three consecutive planned caesarean section70 or if the caesarean section is carried out after the onset of labour.12 In fact, in women aged 50–64 years, the prevalence of SUI was found to be high irrespective of the route of delivery (28.6% after caesarean section and 30% after vaginal births).71
Factors involved in the persistence of stress urinary incontinence from pregnancy to 2 years post partum
2011, International Journal of Gynecology and ObstetricsCitation Excerpt :Specifically, it has been reported that up to 32% of primigravid women develop this symptom during pregnancy [2]. Although most women recover their pre-pregnancy continence status within 8 weeks of delivery [3], a significant percentage of women have persistent symptoms in the postpartum period. The prevalence of persistent SUI varies widely from 5% to 92% [4–7].
Significant Linkage Evidence for a Predisposition Gene for Pelvic Floor Disorders on Chromosome 9q21
2009, American Journal of Human GeneticsCitation Excerpt :Risk factors typically focus on defects in the pelvic floor musculature or connective tissue weakness. Childbirth is the most studied risk factor;3 vaginal delivery, especially with forceps, increases the risk of urinary incontinence, but cesarean delivery is not entirely protective.4 Other risk factors include increased age, smoking, and chronic increased intra-abdominal pressures such as occupational lifting, obesity, and chronic constipation.3
Levator ani denervation and reinnervation 6 months after childbirth
2009, American Journal of Obstetrics and GynecologyBirth and the pelvic floor
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