Does cesarean section prevents from pelvic floor disorders ? Xavier Deffieux (MD, PhD) Gynecologic Surgery, Antoine Be

1. Does cesarean section prevents from pelvic floor disorders ? Xavier Deffieux (MD, PhD) Gynecologic Surgery, Antoine Beclere Hospital, Clamart University of Paris (France) Tehrān, 2010

2. Does cesarean section prevents from pelvic floor disorders ?

3. Does cesarean section prevents from pelvic floor disorders ? China 2010 50% India 18% WHO (World Health Organization) “A C-section > 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

5. Does cesarean section prevents from pelvic floor disorders ? China 2010 50% India 18% Why so many elective C sections in the world ?

6. 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

7. Does cesarean section prevents from pelvic floor disorders ? Thus…the 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 > 30 g/m2 = risk factor of urinary incontinence at long term follow-up [Fritel, BJOG, 2005]

8. Does cesarean section prevents from pelvic floor disorders ? Does caesarean section prevents from pelvic organ prolapse and sexual dysfunction ?

9. 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

10. 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 (n=135) vaginal delivery (n=864) At 3 months follow-up following delivery Unhappy with sexual relations : - 54% following C-section - 70% following vaginal delivery p<0.05 …however, no difference in dyspareunia rates(31% vs 31%)

11. Does cesarean section prevents from pelvic floor disorders ? Randomized controlled trial [Hannah, Am J Obstet Gynecol, 2004]

12. 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 (n=2396) 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

13. Does cesarean section prevents from pelvic floor disorders ? Does caesarean section decreases the risk of urinary incontinence ?

14. 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

15. Does cesarean section prevents from pelvic floor disorders ? Cohort study n=949 Short term follow-up

16. Does cesarean section prevents from pelvic floor disorders ? Cohort study n=949

17. Does cesarean section prevents from pelvic floor disorders ? Prospective study 363 primiparous women No difference

18. Does cesarean section prevents from pelvic floor disorders ? Randomized controlled trial [Hannah, Am J Obstet Gynecol, 2004]

19. Does cesarean section prevents from pelvic floor disorders ? Long term follow-up…

20. Does cesarean section prevents from pelvic floor disorders ? Iranian case controls study

21. 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

22. Does cesarean section prevents from pelvic floor disorders ? Does caesarean section decreases the risk of fecal incontinence ?

23. Does cesarean section prevents from pelvic floor disorders ? Loss of bowel control can be devastating

24. 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

25. 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

26. Does cesarean section prevents from pelvic floor disorders ? PRIMA study1219 primiparous womenFaltain et al. Obstet Gynecol 2005 Caesarean section Anal sphincter tear Vaginal delivery The prevalence of fecal incontinence is not different following normal vaginal delivery and C-section

27. 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-analyse Elective C-section vs VB 3 studies(n=2396) 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

30. 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 > 40 years old