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Elective (Primary) Cesarean Section: Two Very Different Viewpoints?

Elective (Primary) Cesarean Section: Two Very Different Viewpoints?. Kenneth Griffis, MD Urogynecology & Reconstructive Pelvic Surgery. Introduction. Discuss Elective cesarean section Pelvic floor disorders Vaginal delivery. Topics of Discussion. Pelvic organ prolapse

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Elective (Primary) Cesarean Section: Two Very Different Viewpoints?

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  1. Elective (Primary) Cesarean Section: Two Very Different Viewpoints? Kenneth Griffis, MD Urogynecology & Reconstructive Pelvic Surgery

  2. Introduction • Discuss • Elective cesarean section • Pelvic floor disorders • Vaginal delivery

  3. Topics of Discussion • Pelvic organ prolapse • Urinary incontinence • Fecal incontinence • Legal • Ethical

  4. 4 Million Births Annually in the United States

  5. The problem with human childbirth: A large object must pass through a constricted channel with both the object and the channel emerging unscathed...

  6. Is There Structural Damage?

  7. Average peak pressure during Contraction 329 cm H2O Rempen, J. Perinat Med 19(1991) 115-120

  8. Vaginal wall, muscle, connective tissue, and nerve stretch and tear

  9. “It is thus evident that most of the damage resulting from labor is due to injury, rupture, distraction and displacement…” DeLee 1920

  10. Pelvic floor tone & strength after vaginal delivery

  11. 40 30 41% # of patients 20 34% 25% 10 0 stage 0 stage 1 stage 2 Postpartum Anterior Vaginal Wall Prolapse

  12. Rest Valsalva

  13. Fascial white line Muscle white line Pubovesical muscle Pubocervical hammock Rectovaginal septum Vaginal Delivery Associated with Urethral Hypermobility

  14. Rectal Prolapse

  15. Anal Sphincter Lacerations • 2 million vag del CA 1992-1997 • ASL = 5.85% Handa OBG 2001

  16. Anal Sphincter

  17. Rectovaginal fistula

  18. Postpartum Anal Sphincter • Endoanal sonography • 202 women in third tri, 150 6 weeks PP • Sphincter defects • 35% primips, 44% multips • 0/23 with C/S had new defects • 8/10 forceps had new defects Sultan NEJM 1993

  19. Pubococcygeal muscle injury after first birth • 80 primip stress incont women • 80 primip continent women • 9 mos after delivery • 1 in 5 had visible damage to levator ani • 90% involved pubococcygeus • Twice as many levator defects in stress incontinent group as the controls Delancey OBG 2003;101:46

  20. Nerve Injury Gilstrap Operative Obstetrics 2002

  21. Neurophysiologic Evidence • Denervation 42-80% of vag deliveries • Not seen with C/S • Denervation also seen in women with SUI and AI • May be cumulative with  parity

  22. Pelvic Floor Dysfunction and Parity

  23. Prolapse by Vaginal Parity and Stage in Women Seen for Routine Care 70 60 2 1 50 2 40 % 1 30 1 20 2 3 0 0 3 0 10 3 0 Para 0 Para 1-3 Para >3 Swift AJOBG 2000

  24. Parity, Prolapse & Stress Incontinence Mant BJOBG 197;104:579 Rortveit NEJM 2003;348:900 Prolapse Stress Urinary Incontinence Relative Risk Parity

  25. UI 5 Yrs after Vaginal Delivery Viktrup AJOBG 2001 100 80 N = 278 60 % 40 20 0 NO INCONT 1ST PREG INCONT 1ST PREG PERSISTENT INCONT 1ST PREG

  26. Urinary Incontinence AfterVaginal Delivery or Cesarean Section % Rortveit NEJM 2003

  27. Parity and Anorectal Function • 144 women • Age 45-58 • All vaginal deliveries • Mean Parity = 2 • 10 yrs from delivery 3 PNTML 2.8 2.6 msec 2.4 2.2 Decreased Anorectal function using 4 different measures 2 0 1 2 3 4 Parity Ryhammer Dis Colon Rectum 1996

  28. AI 3 months after Delivery7275 women • Primips (n = 3261) • Stool Incontinence 9.0% • Flatal Incontinence 43.4% • Forceps (OR 1.9) • C/S (OR .58) McCarthur BJOBG 2001

  29. AI 3 months after Delivery3261 primiparous women AI Prevalence 9% 14 12 10 OR 1.9 8 % OR 1.3 ns 6 OR 1 4 OR .58 2 0 C/S SVD Vacuum Forceps McCarthur BJOBG 2001

  30. Incidence of Anal Incontinence after Anal Sphincter Laceration • 11 Studies • Europe & US • 1988 – 1996 • Follow-up 3 – 78 mos • n – 563 • Anal Incontinence 20 – 50% (mean 37%)

  31. Episiotomy • No proven benefits • Associated with ASL • Associated with Postpartum AI • Associated with Postpartum Pain

  32. Nulliparous 1st Vag Delivery PMH 1/88-12/00 Vaginal N = 17,715 Spontaneous N = 7140 (40%) Epis N = 8083 (46%) Forceps N = 315 (2%) Forceps + Epis N = 2177 (12%) ASL N = 305 (4%) ASL N = 1590 (20%) ASL N = 85 (27%) ASL N = 1213 (55%)

  33. ASL 2nd Delivery 5  P < 0.001 4 4.4% 3 % 2 1 1.3 % 0 NO ASL 1st Del ASL 1st Del 168/13328 83/1895

  34. What is Known • Vag del causes anatomic injury • Vag del consistent risk factor postpartum UI/AI • ASL risk factor for postpartum AI • Lifetime risk of UI/POP is high • Vag Del is a risk factor for UI later in life • Parity is a risk factor for POP later in life

  35. What is Not Known • Lifetime risk of AI • Relationship between parity and AI • Specific obstetrical risk factors • The impact of other factors • Why is PFD not more common • Who will be affected

  36. VAGINAL DELIVERY • • UI, AI POP Pregnancy RANDOMIZE • • NULLIP q 5 yrs AGE 70 AGE 20 • • UI, AI POP C-SECTION

  37. Culture • First world women are: • more active • less willing to accept pelvic floor problems • Incontinence can destroy sport/recreation/job satisfaction • Culture of litigation (Western world) • Lawsuits related to pelvic floor just a matter of time

  38. Statistics • 10-60% of women report urinary incontinence • Objective studies - lower prevalence • 50% of parous women develop prolapse • Only 10-20% seek medical care

  39. Statistics • Urinary incontinence • 10-25% of women age 15-64 • 15-40% of women over age 60 • More than 50% of women in nursing homes • W.H.O. recognizes incontinence as an international health concern

  40. Statistics • Anal incontinence is the current greater“pelvic floor closet issue” • Incidence and prevalence figures vary • Approximately 10% or more women with urinary incontinence have incontinence of flatus or stool • Only 39% of anal incontinence after delivery cleared in 10 months • (MacArthur C,et al: BR J Obstet Gynaecol 104:46-50,1997)

  41. Risk of C/S vs Vaginal • Nonelective C/S rate > 27% might yield higher maternal mortality than universal elective C/S • Universal C/S - extra 1/18000 maternal mortalities • 36 to 360 fetuses saved for each maternal mortality related to elective C/S. (1/50 - 1/500 fetuses suffer disaster in utero after maturity) • Feldman G.B, Freiman J.A; N Engl J Med 312, 1264-1267

  42. Risk of Cesarean birth: • Little data on purely elective C/S in healthy women • Data usually include all C/S • Sweden 1973-79: Mortality rate: • emerg C/S: 0.18/1000 • elective C/S: 0.04/1000 (5:1) • Other studies suggest smaller difference • Risk C/S:vaginal 5:1 (not only elective!) • We can probably do better • heparin, universal A/B prophylaxis, etc. • Lilford RJ et al; Br J Obstet 1990; 97:883-892

  43. Cost of C/S vs vaginal birth: • Depends on society (medical system) • No level playing field in studies • all C/S together • Later prolapse/incontinence related costs • not included • direct & indirect • Thus: most data biased

  44. Lifetime Risk of Surgery for UI or POP 11.1% 7.5% Incidence 4.7% 2.8% 0.9% 0.1% Age Olsen OBG 1997

  45. Surgery statistics (US) • Ratio of surgery for prolapse vs incontinence: 2:1 • Lifetime risk of surgery for prolapse: 11.1% • Estimated re-operative rate: 29% • 1/2 million prolapse surgeries /year (US) • 2030 estimation: 7 mil/y + 2 mil reoperations(Bump R, Norton P: OB/Gyn Clinics 25, # 4, Dec. 1998)(Mailet VT et al: Presentation to AUGS, Sep 1997)

  46. Legal Issues • Informed consent? • Future Lawsuits? • Insurance fraud?

  47. Informed Consent • Culturally based • Difficult and time consuming • NOT appropriate in labor • Taking into consideration • fertility wishes and age • 37 yo wanting 1; vs 20 yo wanting 4 • Full discussion of relative risks, pros/cons • Financial/resource issues - patient/society

  48. Ethical • Failure to inform? • MSAFP for NTD 1:1000 • Genetic Screening 1:300 • Failure to provide care? • Insurance fraud?

  49. Elective cesarean birth for some women? “On the basis of current available evidence, the concept of an elective prophylactic cesarean section being outrageous, has been shattered by the fact that almost a third of female obstetricians would choose it for themselves” Paterson-Brown S; Queen Charlotte’s and Chelsea Hospital, London.Lancet 1996,347:544

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