Elective Cesareans

In this article titled "Too Posh to Push?"the value of elective cesarean (or "c-section") deliveries for childbirth is revisited. Statistics in Britain are referenced, as rates for the procedure have increased from 4.5% in 1970 to nearly 25% today. This trend is stated to have occurred without a corresponding obstetric need for the the procedure. The US has experienced a similar debate, with stories of women demanding an elective surgery, sometimes for the preservation of the pelvic floor, other times because she is interested in avoiding the pain of pushing. Some providers also promote elective cesareans for birth, perhaps due to their own beliefs about potential benefits, or for the value of having more control over a schedule. Regardless of the motivations and beliefs of the patients or providers, pelvic rehabilitation providers can land in the middle of such an important discussion.

The choice about desired birth practices is between a mother, her family, and her providers. At no time is it appropriate for a pelvic rehab therapist to impose an opinion upon a woman who is pregnant. It is, however, most appropriate to answer questions that may arise in relation to musculoskeletal health and about discussions the patient may be hearing or reading about elective cesareans. The literature in the past decade has been decidedly in favor of avoiding vaginal births in order to avoid pelvic floor injuries. The other half of the story is that birth is not the only factor in pelvic floor health and injury, and that cesarean deliveries also carry risks- some of those risks are lessened in a vaginal birth.

Basic information about a cesarean delivery are available on many sites, including the National Institute of Health's MedLinePlus. While c-sections are always described as a "safe" surgery, all surgeries carry risks. Personally, I have been amazed at the nonchalance of surgeons who give an air of "no-big-deal" for common surgeries that is contrasted with the informed consent waiver a person is asked to sign before entering the operating room. All surgeries have risks. While it is acknowledged that vaginal deliveries are associated with increased incontinence, the actual cause of the pelvic floor injuries cannot be directly correlated with the delivery itself.

A recent study from Brazilevaluated the use of 3D perineal ultrasound to measure pelvic floor injuries at the second postpartum day. 35 patients were allocated to groups according to delivery type: elective cesarean (10), vaginal delivery (16), and forceps delivery (9), with episiotomy performed in 3 of the deliveries. The urogenital hiatus was found to be significantly increased from the cesarean group, at 12.4 cm, to 17 cm in the vaginal delivery group and 20.1 cm in the forceps delivery group. 3 of the 25 women in the non-cesarean groups had a tear of the levator ani. The authors recommend routine assessment of pelvic floor integrity following childbirth. While vaginal birth may be correlated with increased rates of incontinence and prolapse, a recentstudy that evaluated 84 women (grouped by mode of delivery) did not find any correlation between mode of delivery and return to sexual function.

The controversy is far from over, as we continue to see research that aims to answer questions about long-term benefits for pelvic floor health in relation to cesarean versus vaginal deliveries. As is often the case, the swinging pendulum that headed towards recommending elective cesareans will likely swing back towards the middle ground when more research comes in, and when more providers and women understand the total implications of various birth practices on not only the mother and child, but on families and communities as well. In the meanwhile, pelvic rehabilitation providers will continue to support a woman regardless of birth history, focusing instead on patient presentation, goals, and examination findings when applying best practices.