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

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Presentation on theme: "Elective (Primary) Cesarean Section: Two Very Different Viewpoints? Kenneth Griffis, MD Urogynecology & Reconstructive Pelvic Surgery."— Presentation transcript:

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)

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 The head advancing through the hiatus genitalis : Stretches the vagina, wipes it off its fascial anchorings Stretches pelvic fascia over levator, wipes away rectal fascial anchorings Tears the levator fascia causing levator diastasis Tears the levator muscle at its insertion & lateral to the rectum Ruptures the urogenital septum Joseph Bolivar DeLee (1920)

12 Postpartum Anterior Vaginal Wall Prolapse stage 0 stage 1 stage 2 # of patients 25% 34% 41%

13 Rest Valsalva

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

15 Rectal Prolapse

16 Anal Sphincter Lacerations 2 million vag del CA million vag del CA ASL = 5.85%ASL = 5.85% Handa OBG 2001

17 Anal Sphincter

18 Rectovaginal fistula

19 Postpartum Anal Sphincter Endoanal sonographyEndoanal sonography 202 women in third tri, weeks PP202 women in third tri, weeks PP Sphincter defectsSphincter defects –35% primips, 44% multips 0/23 with C/S had new defects0/23 with C/S had new defects 8/10 forceps had new defects8/10 forceps had new defects Sultan NEJM 1993

20 Pubococcygeal muscle injury after first birth 80 primip stress incont women80 primip stress incont women 80 primip continent women80 primip continent women 9 mos after delivery9 mos after delivery 1 in 5 had visible damage to levator ani1 in 5 had visible damage to levator ani 90% involved pubococcygeus90% involved pubococcygeus Twice as many levator defects in stress incontinent group as the controlsTwice as many levator defects in stress incontinent group as the controls Delancey OBG 2003;101:46

21 Gilstrap Operative Obstetrics 2002 Nerve Injury

22 Neurophysiologic Evidence Denervation 42-80% of vag deliveriesDenervation 42-80% of vag deliveries Not seen with C/SNot seen with C/S Denervation also seen in women with SUI and AIDenervation also seen in women with SUI and AI May be cumulative with  parityMay be cumulative with  parity

23 Pelvic Floor Dysfunction and Parity

24 Para 0 Para 1-3 Para >3 Prolapse by Vaginal Parity and Stage in Women Seen for Routine Care % Swift AJOBG

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

26 UI 5 Yrs after Vaginal Delivery NO INCONT 1 ST PREG INCONT 1 ST PREGPERSISTENTINCONT 1 PREG 1 ST PREG % Viktrup AJOBG 2001 N = 278

27 Urinary Incontinence After Vaginal Delivery or Cesarean Section % Rortveit NEJM 2003

28 Parity and Anorectal Function Parity msec PNTML 144 women 144 women Age Age All vaginal deliveries All vaginal deliveries Mean Parity = 2 Mean Parity = 2 10 yrs from delivery 10 yrs from delivery Ryhammer Dis Colon Rectum 1996 Decreased Anorectal function using 4 different measures

29 AI 3 months after Delivery 7275 women McCarthur BJOBG 2001 Primips (n = 3261) – Stool Incontinence 9.0% – Flatal Incontinence 43.4% – Forceps (OR 1.9) – C/S (OR.58)

30 AI 3 months after Delivery 3261 primiparous women C/SSVDVacuumForceps % OR 1 OR.58 OR 1.3 ns OR 1.9 AI Prevalence 9% McCarthur BJOBG 2001

31 Incidence of Anal Incontinence after Anal Sphincter Laceration 11 Studies11 Studies Europe & USEurope & US 1988 – – 1996 Follow-up 3 – 78 mosFollow-up 3 – 78 mos n – 563n – 563 Anal IncontinenceAnal Incontinence 20 – 50% (mean 37%)

32 Episiotomy No proven benefitsNo proven benefits Associated with ASLAssociated with ASL Associated with Postpartum AIAssociated with Postpartum AI Associated with Postpartum PainAssociated with Postpartum Pain

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

34 ASL 2 nd Delivery % 4.4% 168/ /1895 P < NO ASL 1 st Del ASL 1 st Del % 

35 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

36 What is Not Known Lifetime risk of AILifetime risk of AI Relationship between parity and AIRelationship between parity and AI Specific obstetrical risk factorsSpecific obstetrical risk factors The impact of other factorsThe impact of other factors Why is PFD not more commonWhy is PFD not more common Who will be affectedWho will be affected

37 UI, AI POP UI, AI POP NULLIP AGE 20 q 5 yrs AGE 70 VAGINALDELIVERY C-SECTION Pregnancy RANDOMIZE

38 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

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

40

41 Statistics  Urinary incontinence  10-25% of women age  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

42 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)

43 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,

44 Risk of Cesarean birth:  Little data on purely elective C/S in healthy women  Data usually include all C/S  Sweden : 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:

45 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

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

47 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)

48 Legal Issues Informed consent? Future Lawsuits? Insurance fraud?

49 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

50 Ethical Failure to inform? –MSAFP for NTD 1:1000 –Genetic Screening 1:300 Failure to provide care? Insurance fraud?

51 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

52 Prevention of Childbirth Injuries to the Pelvic Floor Heit et al. Current Women’s Health Reports 2001 “Elective c/s for all pregnant women may not be as unrealistic as it sounds……17% of obstetricians chose elective c/s for themselves or their partners in the absence of any clinical indication….Consumer demand could contribute to rising c/s rates because women envision greater freedom of choice….These choices are not based on a knowledge deficit because 1/3 of the most knowledgeable patients (female Ob/Gyn’s) would choose elective c/s for themselves.”

53 Future of Pelvic Floor Dysfunction Elective C/S for every pregnancy Prevention Identification of Risk Factors No! Yes! Yes!

54 Future of Pelvic Floor Dysfunction Elective C/S for some pregnancies after informed consent after informed consent Prevention Antenatal risk counselling Yes! Yes! Yes!

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