Why Not Request a Cesarean Delivery, to Prevent Incontinence?

Should women be permitted to accept the risks of cesarean in order to possibly reduce their risk of developing incontinence, prolapse, and pelvic floor problems later on?  This is a topic being actively debated in women’s health – one surrounded by complex medical, economic and social questions.  At the very least, women should have the option of informing themselves on different childbirth strategies, and learning about what the potential repercussions of these choices may be.

The risks of cesarean delivery need to be seriously considered.  Although this operation under spinal or epidural anesthesia is safer today than at any time in the past, a cesarean section is an operation that carries potentially serious risks to both mother and baby – which need to be carefully discussed.  The debate over ‘cesarean by choice’ is a perfectly legitimate one, so long as the potential hazards of this operation are never overlooked.

The benefits of cesarean may include less urinary incontinence, anal injury, and pelvic floor injury – due to less nerve, muscle and tissue strain.  Though not totally eliminated, stress urinary incontinence is far less common (up to 50% less) after cesarean compared with vaginal birth.  Serious injuries to the anal sphincter are rare after cesareans that are performed before labor begins.  Pelvic organ prolapse is also less common.

‘Cesareans for all’ obviously cannot be justified for the prevention of pelvic injury alone.  Therefore, the challenge is to identify those women most at risk – and encouraging women to discuss their potential risk factors with their doctor or midwife.  Also, it should be understood that not all cesareans are ‘equal’ in terms of their potential benefit.  The most protective of all – the ones that most reliably help to avoid pelvic floor injuries – appear to be those performed in the first pregnancy, before labor ever begins.  Cesareans performed after the onset of labor may be less protective.

Childbirth choices should be individualized.  Each pregnancy is a unique combination of mother and baby, making each and every labor and delivery a singular event.  As a result, a single obstetrical strategy, or an ‘ideal’ mode of delivery cannot be applied to all expectant women.  In some cases, a prolonged labor, a forceps extraction, or an extensive perineal injury during vaginal birth may be more physically traumatic for both mother and baby than a cesarean section.  For others, the exact opposite will be true.

Adapted From:  “Ever Since I Had My Baby: Understanding, Treating and Preventing the Most Common Physical Aftereffects of Pregnancy and Childbirth”, by Roger P. Goldberg, MD MPH

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