Obstetric practice and the pelvic floor

Abstract

A vaginal delivery has a profound impact on the pelvic floor with the potential for significant functional sequelae. There is an increasing trend among obstetricians to perform a caesarean section to preserve pelvic floor function. This in turn has contributed to an increasing caesarean section rate, both in South Africa and internationally. What impact does vaginal delivery have on pelvic floor dysfunction and can we prevent these problems by resorting to an abdominal delivery? When it comes to preventing urinary incontinence, caesarean section has been shown to be protective; reducing the risk by about 50%, but the effect appears to dissipate with time. For faecal incontinence, caesarean delivery has only a marginal impact with one study showing that 167 caesarean sections need to be done to prevent one case of faecal incontinence. Forceps delivery appears to double the risk of faecal and urinary incontinence compared to normal vaginal delivery. In terms of sexual function, caesarean section is associated with a sensation of better vaginal tone for both partners but no difference in any other parameters. Vaginal delivery is significantly associated with pelvic organ prolapse, with the risk rising with increased vaginal parity. caesarean section is strongly protective against the development of prolapse. This should be viewed in the context of an increased mortality rate for elective caesarean section, with one study showing this to be about 3.6 times that of vaginal delivery. Every women embarking on a caesarean delivery to protect her pelvic floor should be counselled by her obstetrician about the limitations and risks of this procedure.

Keywords: Caesarean section; Incontinence; Pelvic organ prolapse