Does cesarean section prevents from pelvic floor disorders ?

1
Does cesarean section prevents from pelvic floor
disorders ? Xavier Deffieux (MD,
PhD) Gynecologic Surgery, Antoine Beclere
Hospital, Clamart University of Paris (France)
Tehran, 2010
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Does cesarean section prevents from pelvic floor
disorders ?
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Does cesarean section prevents from pelvic floor
disorders ?
China 2010 50
India 18
WHO (World Health Organization) A C-section gt
15 indicates that too many unnecessary
C-sections are being performed
4
Does cesarean section prevents from pelvic floor
disorders ?
China 2010 50
India 18
Caesarean section raises the risk of
complications for the mother The cost of
C-section is higher than natural birth
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Does cesarean section prevents from pelvic floor
disorders ?
China 2010 50
India 18
Why so many elective C sections in the world ?
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Does cesarean section prevents from pelvic floor
disorders ?
When asked why women prefer C-section almost
all recounted problems with -
fetal distress and mortality -
excessive pain - trauma to the
vagina and potential pelvic floor disorders
(urinary incontinence, fecal
incontinence, dyspareunia) It is important for
every woman to understand what she can do to
protect her pelvic floor and avoid pelvic floor
disorders Informed consent is required before
choice of delivery mode Obstetricians and
gynecologists must inform women concerning this
point
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Does cesarean section prevents from pelvic floor
disorders ?
Thusthe question is  Does caesarean section
prevents from pelvic floor disorders ?  Urinary
and fecal incontinence, POP, sexual
dysfunction Hypothesis - Vaginal delivery is
the etiology of pelvic floor dysfunction -
Caesarean section (Cs) avoid vaginal delivery -
Conclusion Cs prevents from pelvic floor
dysfunction First point Vaginal delivery is not
the unique etiology of pelvic floor
dysfunction BMI gt 30 g/m2 risk factor of
urinary incontinence at long term follow-up
Fritel, BJOG, 2005
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Does cesarean section prevents from pelvic floor
disorders ?
Does caesarean section prevents from pelvic
organ prolapse and sexual dysfunction ?
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Does cesarean section prevents from pelvic floor
disorders ?
Does C-section prevents from POP surgery
? Case controls study (7556 primiparous
women) Case women who have undergone POP
surgery Controls women who did not
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Does cesarean section prevents from pelvic floor
disorders ?
Does C-section prevents from sexual dysfunction
? Klein, J Obstet Gyaecol Can,
2005 Prospective cohort study C-section (n135)
vaginal delivery (n864) At 3 months follow-up
following delivery Unhappy with sexual relations
- 54 following C-section - 70 following
vaginal delivery plt0.05 however, no
difference in dyspareunia rates(31 vs 31)
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Does cesarean section prevents from pelvic floor
disorders ?
Randomized controlled trial Hannah, Am J Obstet
Gynecol, 2004
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Does cesarean section prevents from pelvic floor
disorders ?
Does C-section prevents from sexual dysfunction
? Cochrane Database Meta-analysis Elective
C-section vs vaginal delivery 3 studies
(n2396) At 3 months post-partum Perineal
pain RR 0.32 95 CI 0.1-0.5 Dyspareunia
RR 0.91 95 CI 0.7-1.1 NS At 2 years
post-partum Sexual dysfunction RR 0.95 95 CI
0.6-1.4 NS Perineal pain RR 0.65 95 CI
0.3-1.1 NS Unhappiness with sex RR 0.87 95
CI 0.5-1.5 NS
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Does cesarean section prevents from pelvic floor
disorders ?
Does caesarean section decreases the risk of
urinary incontinence ?
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Does cesarean section prevents from pelvic floor
disorders ?
Caesarean section is unable to prevent all
urinary incontinence because vaginal delivery is
not the only etiology of urinary incontinence
Pregnancy itself plays a major role
Deffieux et al, 2010
Prevalence of urinary symtpoms
USI
UUI
12 wg
28 wg
36 wg
3 M PP
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Does cesarean section prevents from pelvic floor
disorders ?
Cohort study n949
Short term follow-up
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Does cesarean section prevents from pelvic floor
disorders ?
Cohort study n949
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Does cesarean section prevents from pelvic floor
disorders ?
Prospective study 363 primiparous women
No difference
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Does cesarean section prevents from pelvic floor
disorders ?
Randomized controlled trial Hannah, Am J Obstet
Gynecol, 2004
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Does cesarean section prevents from pelvic floor
disorders ?
Long term follow-up
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Does cesarean section prevents from pelvic floor
disorders ?
Iranian case controls study
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Does cesarean section prevents from pelvic floor
disorders ?
Mid-urethral slings (TVT) and pregnancy No
randomized controlled trial Cases
series Literature review 29 case
reports Recurrence rate of urinary incontinence
- 3 (21 ) following C section - 4 (26 )
following vaginal delivery
no difference C-section is not recommended in
pregnant women with TVT
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Does cesarean section prevents from pelvic floor
disorders ?
Does caesarean section decreases the risk of
fecal incontinence ?
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Does cesarean section prevents from pelvic floor
disorders ?
Loss of bowel control can be devastating
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Does cesarean section prevents from pelvic floor
disorders ?
External anal sphincter injury (anal sphincter
tear)
Anal sphincter injury during vaginal
delivery Sultan et al NEJM 1993
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Does cesarean section prevents from pelvic floor
disorders ?
Does caesarean section decreases the risk of
fecal incontinence ? Prospective study
(nulliparous women) Chaliha, Am J Obstet
Gynecol, 2001 Fecal incontinence before
pregnancy 2 Fecal incontinence during
pregnancy 15 Among women presenting with
fecal incontinence 45 do not present any anal
sphincter injury
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Does cesarean section prevents from pelvic floor
disorders ?
PRIMA study 1219 primiparous womenFaltain et
al. Obstet Gynecol 2005
Anal sphincter tear
Caesarean section
Vaginal delivery
The prevalence of fecal incontinence is not
different following normal vaginal delivery and
C-section
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Does cesarean section prevents from pelvic floor
disorders ?
100 cesarean sections a solution ?
9.4
9.0
250 C-section deliveries should be performed to
prevent one case of fecal incontinence related to
anal sphincter injury
28
Does cesarean section prevents from pelvic floor
disorders ?
Randomized controlled trial Hannah, Am J Obstet
Gynecol, 2004
29
Does cesarean section prevents from pelvic floor
disorders ?
Does caesarean section decreases the risk of
fecal incontinence ? Cochrane Database Meta-analy
se Elective C-section vs VB 3 studies(n2396)
3 months follow-up afterdelivery Fecal
incontinence RR 0.54 95 CI 0.1-1.6 NS 2
years follow-up Fecal incontinence RR 1.11 95
CI 0.4-2.5 NS
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Does cesarean section prevents from pelvic floor
disorders ?
Conclusion Elective C-section (with no trial of
labour) is associated with a lower prevalence of
post-partum urinary incontinence (at 3 months
FU) However C-section do not prevents from
long term urinary or fecal incontinence C-section
do not prevents from long term sexual disorders
31
Does cesarean section prevents from pelvic floor
disorders ?
Conclusion Scientific data is insufficient to
justify an elective cesarean section in order to
avoid pelvic floor symptoms
32
Does cesarean section prevents from pelvic floor
disorders ?
Conclusion Further studies are required in high
risk women - women with previous pelvic floor
disorders - age gt 40 years old