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Family Health Magazine - CHILDBIRTH

Childbirth and the Pelvic Floor
Will a planned c-section prevent problems?

After childbirth, a woman’s life is never the same again. Becoming a mother forever changes her personal, work and social life. What about her physical health? Does childbirth permanently affect the body, and are these changes a problem? As interest in the quality of life after childbirth increases, the controversy about childbirth’s effect on the pelvic floor is also rising.

How pregnancy affects the pelvic floorWhat is the pelvic floor?

The pelvic floor is a hammock-like muscular structure supporting the uterus, vagina, bladder and rectum. If it stretches or sags, the organs it supports may not work properly. Urinary incontinence (loss of urine when coughing or sneezing, or an urgent need to get to the toilet) can be one result. Very rarely, feces (stool) or gas may be lost through the rectum. A loose pelvic floor can also create sexual problems, including lack of sensation and less satisfaction. These problems can occur whether you have a vaginal or caesarean birth. Women who have never had a baby can also develop pelvic floor problems.

The media spotlight

Media coverage of the decisions by certain celebrities to decide in advance to have caesareans has stimulated much discussion. Some women are afraid of the pain of vaginal childbirth, while others want to protect the pelvic floor from damage. Bowel, bladder and sexual function are also issues. Some women with especially complex lives find the ability to schedule a caesarean attractive. Many women hope to eliminate future problems by choosing caesarean section. Some doctors share these concerns about the pelvic floor, and believe avoiding labour through a caesarean section can protect women.

Informed consent

Whether a woman requests a caesarean for medical or personal reasons, a full discussion needs to take place. Benefits and risks exist with both caesarean and vaginal birth, but they are not the same. A complete discussion of risks and benefits of each choice is called informed consent.

The Society of Obstetricians and Gynecologists of Canada (SOGC) has determined that unless a woman has a particular medical or surgical problem, vaginal birth is safest. This is true not only the first time that a woman gives birth, but also for later pregnancies.

When considering possible damage to the pelvic floor, women need to weigh the risks of vaginal birth against all immediate and long-term risks of caesarean. This includes quality-of-life differences between vaginal and caesarean birth, psychological impact, and how a caesarean can affect future pregnancies and health. The successes of breastfeeding and the baby’s adjustment in early life are also considerations. Proper birth techniques may also help safeguard the pelvic floor. All of these factors make the discussion very complex.

Summarizing everything you hear to make an informed decision can be both overwhelming and time-consuming. Ultimately, each woman must decide for herself how the information fits her unique situation.

Problems with existing research

Research on pelvic floor problems comparing vaginal birth with caesarean is hard to understand. Opinions vary greatly, as the study of these issues is made more difficult by numerous factors.

Pelvic Floor Effects of Vaginal and Caesarean Birth

Differences in birthing

Currently available studies cannot distinguish between vaginal births with a less invasive approach compared to those using medical interventions such as induction, epidurals or continuous electronic heart rate monitoring. Gentle birth involves women pushing naturally, without stirrups or the routine use of episiotomy. This tends to protect the pelvic floor and perineum (the tissue between the base of the vagina and the rectum). Such births have not been directly compared to caesareans. Rather, all births are used for comparison, including those involving many medical interventions.

Obstetricians are very skilled at performing caesareans. Fewer obstetricians are comfortable with assisting vaginal birth using forceps or a vacuum because of malpractice concerns. Those that do, mostly older obstetricians who can do a gentle instrumental delivery, find many younger colleagues are less interested in acquiring this skill.

If caesarean can protect the pelvic floor, it is crucial to discover whether this effect is always associated with caesarean, or only when it is done before labour. Does caesarean protect more than a normal vaginal birth? If forceps and vacuum are used, do they bring the baby all the way through the birth canal, or just the last little bit? Such details are not available in most studies to date. However, they are extremely important, as no two births are ever the same.

Urinary incontinence

Studies have demonstrated that urinary incontinence (from a few drops of leaked urine to regular use of a protective pad) is more likely after vaginal birth compared with any caesarean (before or during labour). This is particularly true in the first three months following birth.

Women who have never given birth have a one in ten risk of developing urinary incontinence before menopause. This risk increases to about one in five among women with only a history of caesareans and to one in four among women with only a history of vaginal births. But urinary incontinence is found in approximately one in three of women over the age of fifty, whether they gave birth vaginally or by caesarean. In other words, although urinary incontinence is more likely during the childbearing years, after menopause, the likelihood of having urinary incontinence is similar whether they gave birth vaginally, by caesarean or not at all.

Stress urinary incontinence is leakage with straining such as coughing and sneezing. Urge incontinence is leakage that occurs with a sudden need to rush to the toilet. The small, short-term protective effect of caesarean appears to be linked mainly to stress urinary incontinence. However, when only the risk of severe urinary incontinence (needing to use a pad) is examined, caesarean has little or no protective effect. Three months after their most recent birth, women who reported any symptoms of urinary incontinence were equally likely to wear a pad whether they had a vaginal birth or a caesarean. This was more likely if they had more than one birth, but there was no difference between the two types of birth.

The chances of experiencing severe urinary incontinence before menopause are 3.7% if a woman has never given birth, 6.2% if they gave birth by caesarean section and 8.7% if they gave birth vaginally.

For women having a breech (buttocks-first) birth, urinary incontinence was no different two years after vaginal or caesarean delivery. This study and others demonstrate that the pelvic floor is resilient, able to recover and heal itself.

Fecal incontinence

While most distressing, fecal incontinence (the loss of control of a bowel movement or gas) is very rare. Again, three months after both caesarean and vaginal birth, some women did report some loss of control of their bowels. Studies have not shown a difference in fecal incontinence following elective caesarean before labour compared with one performed during labour. It is slightly more common after vaginal birth and even more likely after forceps or vacuum. Severe perineal tears and slower recovery are more likely in births using instruments and episiotomy than with vaginal births without episiotomy.

Sexual Issues

There is no question that pregnancy and childbirth affect sexual health, especially in the first three months after delivery. Issues include painful intercourse, vaginal dryness even when sexually aroused, a lack of sexual desire, and less satisfaction. The turmoil in a woman’s and a couple’s lives go far beyond the process of childbirth. Hormone changes, breastfeeding issues, sleep disturbances, new responsibilities, sharing affection with baby, and a number of significant stresses all arrive at the same time.

Intercourse is commonly more painful for the first little while after any type of delivery. More than half of women report pain in the first three months. The number rises if delivery was instrumental (using forceps or vacuum). However, by six months after birth, there was no difference in pain during sex whether delivery was vaginal, instrumental or caesarean. Experiencing pain one year after delivery was more likely if a caesarean was done after a failed attempt at forceps or vacuum.

Similarly, for other sexual issues listed there was no difference between vaginal or caesarean birth. Not surprisingly, sexual satisfaction was low for almost everybody during the very early postpartum time.

Is it the pregnancy or the birth?

Some believe that it is just being pregnant or having the baby’s head drop into the pelvis that leads to incontinence. Others think it is the full birth process that leads to pelvic floor problems. All studies do not come to the same conclusion. In many studies, it appears that one year after giving birth, urinary incontinence is slightly less likely if caesarean took place before labour starts in comparison with one done during labour.

While it may seem that the use of forceps or vacuum increases the frequency of urinary incontinence, a review of the best of these studies shows little difference when compared to vaginal birth without instruments. The slight protective effect of caesarean over vaginal birth mainly seems true for women having their first births.

Usually, using forceps means routine use of episiotomy, which in turn is associated with excess severe perineal (and rectal) trauma. When episiotomy is not done routinely, rectal trauma is much less likely. If episiotomy is used only when really necessary with instrumental deliveries, rectal trauma will not occur as often, leaving even less difference between vaginal birth and caesarean.

How many caesareans does it take to prevent one case of incontinence?

Perhaps this is the easiest way to think about such complex and confusing information. In studies that looked at urinary incontinence at least one year after the birth, the number of planned caesareans needed to prevent one case of unspecified urinary incontinence of any severity was at least eight. For stress urinary incontinence, the number is about 16. For severe unspecified urinary incontinence, the number of caesareans to prevent one case was 32. And for severe stress urinary incontinence the number of preventative caesareans is almost 100. Remember with vaginal births, these studies are almost certainly done under less than ideal conditions compared to caesarean. The bottom line is that caesarean section is not likely to prevent severe urinary incontinence. Doing routine caesareans to prevent urinary incontinence exposes both women and their newborns to some significant risks.

To prevent one case of mild to severe fecal incontinence, 40 to 50 planned caesarean sections would be necessary. Or, 40 to 50 vaginal births must be avoided, depending on whether forceps or vacuum are involved in some of these births.

What does this mean?

The message for both women and health professionals is that how we handle vaginal birth should improve. Women should not have to choose between difficult vaginal birth, with or without forceps, and caesarean.

Although urinary incontinence is more likely after a vaginal birth, it is usually only short-term. Choosing a planned caesarean only slightly reduces the risk. We also do not know whether women are really bothered by such symptoms. The risk of severe urinary incontinence, even short-term, seems to be the same with both vaginal and caesarean birth. As well, the chances of this being a lifelong problem are not linked to vaginal birth. In making birthing decisions, each woman must consider these complex outcomes, her own value system and quality-of-life issues.

Fecal incontinence is slightly more likely after any birth, particularly one involving instruments. Caesareans may slightly reduce the incidence of postpartum fecal incontinence. This effect seems similar whether the caesarean is planned or performed during labour.

Short-term sexual problems are common following any birth. However, there is little evidence that caesarean helps improve this over the long term. Instrumental births may be more likely to create sexual problems than either spontaneous vaginal birth or caesarean section.

The Big Picture

Many medical issues beyond the pelvic floor must be taken into account when considering the issue of caesarean by choice. These include surgical and medical illness in mother or baby that can result from that choice, along with the extra health care cost of caesareans. Women also need to consider potential future risks such as placental problems and pelvic scars from surgery which can lead to bowel obstruction, infertility, and tubal pregnancies. All increase with each caesarean. A recent major Canadian study supports other research from France, Latin America and the United States that suggests that illness and complications are more likely in both mother and baby following planned caesarean sections, while vaginal births appear to protect.

Women's requests for elective caesarean can involve deeply held beliefs. Among many reasons, women may hope to avoid pain (which can be greatly reduced with epidural analgesia), to stay in control, or to check the unpredictable nature of labour. Postpartum pelvic floor problems are certainly an important issue in avoiding both symptoms, but these need to be balanced against the risk associated with surgical treatment.

Still, the chance of requiring surgery for urinary incontinence later in life is significantly affected by the number of births a woman has had—regardless of type of delivery. Women who have had one birth are more than three times more likely to have surgery than those who have never given birth. This rises to five times after two births and to more than six and a half times after three births. Recognizing the impact of more than one birth may be more important than differences between vaginal or caesarean delivery. Family medical history may also play a role. Fortunately, women can take action in many other ways to reduce the chances of becoming incontinent.

What can I do to protect my pelvic floor?

Quitting smoking, maintaining a healthy weight and avoiding hormonal therapy during menopause go a long way toward lowering the risk of urinary incontinence. Doing pelvic floor exercises during pregnancy and throughout life can help maintain the best pelvic floor strength and function. If you have problems after delivery, talk to your maternity care provider about them as soon as possible. This allows you to get the treatment you need and reduces the risk of long-term problems.

Although we know that forceps or vacuum may affect aspects of pelvic floor functioning, it is not possible to predict which women will need forceps or vacuum during a vaginal birth. Hopefully, most women have the chance to choose their own caregiver. Selecting a provider who believes in natural, non-invasive methods during birth makes it more likely that her pelvic floor will be protected.

Each woman has the right to guide the direction of her labour. The birth process depends on a mother’s unique labour experience, the progress of labour, and her values. When discussing choices, care providers should counsel carefully and without bias. Certain problems related to vaginal birth are related to obstetric habits that have developed over time. Routine use of episiotomy, routine use of epidurals, prolonged bearing-down pushing, delivering in stirrups or other gravity-defeating positions – all can damage the pelvic floor and perineum. Wise choices made during birth would likely reduce the difference between vaginal and caesarean pelvic floor outcomes even further.

Evidence suggests that planned caesarean is only slightly better than in-labour caesarean in preventing short-term incontinence, but not in preventing severe urinary incontinence. However, the risk of fecal incontinence seems similar after elective or in-labour caesarean. As well, much fecal incontinence may be associated with the use of instruments.

A woman very fearful of fecal incontinence may decide to go through labour, with the understanding that she may choose a caesarean even if her doctor suggests using forceps or vacuum. As well, if a birth does require instruments, the mother can ask that episiotomy be avoided if possible. This will help reduce perineal and pelvic floor damage.

Making a final decision

Women need to be fully informed about all of their options. To make an informed decision, pelvic floor information must be considered along with the risks and benefits of surgery compared with vaginal birth. This time-consuming process will likely take more than a single visit. Resources exist to provide women with the information they need to make choices about childbirth. The Maternity Collaboration has such material available both online or in print. Those women hoping to prevent pelvic floor problems when giving birth vaginally may want to check the link www.childbirthconnection.org (search for ‘pelvic floor’).

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FAMILY HEALTH is written with the assistance of
Alberta College of Family Physicians
FAMILY HEALTH is written
with the assistance of
The College of Family Physicans of Canada
Alberta College of Family Physicians
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