TORONTO—Caesarean deliveries significantly reduce the risk of prolapse compared with vaginal delivery, according to a data presented at the joint International Continence Society—International Urogynecological Association annual meeting – but only if women had all their deliveries by Caesarian. Having even one baby vaginally removed this effect.
Based on survey responses from 3,763 women initially recruited three months after they had delivered a baby, the data showed women who had only given birth by Caesarean section had an 88% lower risk of future prolapse 12 years later compared with spontaneous vaginal deliveries.
In addition, investigators observed a significantly higher risk of prolapse among women having their first child after age 30. Having more than one child also predicted an extra risk of prolapse. Obesity was not associated with prolapse risk.
Twelve years after the initial survey, the women were invited to attend an examination for prolapse, using the Pelvic Organ Prolapse Quantification system. A total of 678 women were examined. These women had a mean age of 43 years and 20 had undergone prolapse surgery, 59% had stage 2 or higher prolapse, and 26% had stage 2b or higher prolapse. Of the 678 women, 53 had only Caesarean deliveries and 343 had only spontaneous vaginal deliveries.
Only 6% of the 53 with only Caesaran deliveries had experienced a prolapse compared with 29% of those with only spontaneous vaginal deliveries, according to findings presented by lead investigator Cathryn Glazener, MD, a professor in the Health Services Research Unit at the University of Aberdeen, Scotland. Those with both types of deliveries, and any forcep- or vacuum assisted deliveries had similar risks for prolapse as those with vaginal deliveries.
Dr. Glazener and her co-investigators also found that women who had their first child at between 30 and 34 years of age were 2.3 times more likely to experience prolapse than those who had their first child by age 24. Women who had their first child at age 35 or older had a threefold increased risk.
Furthermore, the more children the women had, the more likely they were to experience prolapse. Compared with women who had only one child, those who had two or three children had a 2.6 times and 4.2 times increased risk of prolapse. Women who had four or more children had a nearly fourfold increased risk.
Women who want to reduce their chance of having a prolapse should have only one baby, have that baby by Caeserean section, and have it before they are 30 years old, Dr. Glazener advised.
John DeLancey, MD, the Norman F. Miller Professor of Gynecology and Director of Pelvic Floor Research, Department of Obstetrics & Gynecology, University of Michigan Health System, Ann Arbor, praised the study.
“It’s wonderful that we finally have data to provide for women so that they can consider these facts with many other important decisions about birth,” Dr. DeLancey said after hearing Dr. Glazener’s presentation.
Another authority in the field, Charlotte Chaliha, MD, of the Department of Obstetrics and Gynaecology, Royal London and St Bartholomew’s Hospitals, London, observed: “This is a very interesting study as it is the largest longitudinal prospective study looking at the development of prolapse in association with childbirth.”
Dr. Chaliha noted that the findings are not surprising given the muscle and nerve trauma to the pelvic floor that is more often seen with vaginal delivery. The new study fits with most of the literature, which shows a protective effect from Caesaren deliveries on postpartum urinary and fecal incontinence, she added. She noted, however, that the new study had small numbers of women in the Caesarean group.
It is possible that the protective effect might not be demonstrated if larger numbers of women with Caesarean deliveries are studied Dr. Chaliha pointed out that the researchers did not distinguish between elective versus emergency Caesarean deliveries, and the latter may still result in pelvic floor problems. For instance emergency Caesarean deliveries can result in nerve trauma and damage to the anal sphincter.
Thus, there may be differences in pelvic floor support among women having elective versus emergency Caesarean sections she explained. In addition, before recommending Caesarean deliveries on the basis of potential protection against pelvic floor problems, women need careful counseling regarding the risks of Caesarean deliveries, particularly if they have more than one delivery by this route.