Clinical Review

When does vaginal delivery invite incontinence?

OBG Manag. 2005 August;17(8):44-51

Cesarean or no cesarean, only a few factors can reduce risk of pelvic floor damage, and not all are controllable. What to counsel the worried, incontinent gravida.

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References

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IN THIS ARTICLE

What the evidence does—and does not confirm
Protective factors
Term Breech Trial

Fast Track

Women can have neurologic pelvic floor dysfunction yet have normal findings

30 years after delivery, fecal incontinence is equally prevalent among women who delivered vaginally or by cesarean

Elective cesarean protects only against stress incontinence—not other urinary or fecal symptoms

The effect of delivery on incontinence has perhaps been overstated

Pelvic floor injury is more likely with attempted forceps delivery than with emergent c-section at full dilatation

Term Breech Trial: No differences in incontinence and sexual function between planned cesarean and planned vaginal delivery

MARISOL’S CASE

Pregnant and incontinent

Marisol, a 32-year-old physiotherapist expecting her second child, presents to your antenatal clinic at 20 weeks’ gestation. She complains of urinary incontinence, which has been worsening throughout this pregnancy, and wants to know what can be done about it.

How do you respond?

The bad news is that Marisol’s complaints are not uncommon. The good news: Detailed evaluation and considered discussion can help reveal the full extent of her symptoms and shed light on how to proceed, though, in some cases, your options may be limited. Since we are in the early stages of understanding pelvic floor dysfunction related to pregnancy and childbirth, giving clear advice and guidance can sometimes be difficult. The starting point here, as in any case involving urinary symptoms, is a detailed history to pin down the cause of the patient’s complaints.

In women, urinary incontinence generally stems from overactive bladder or urethral sphincter incompetence; the latter is generally acquired through pregnancy and childbirth.^{Examining the Evidence.)}

Episiotomy also has been associated with diminished pelvic floor muscle strength, compared with spontaneous perineal lacerations.³³

Other factors with protective potential. Some recommendations may reduce the overall risk of incontinence in the long term in the general population, though they do not apply in Marisol’s case. For example, weight reduction in moderately obese women can reduce the risk of urinary symptoms.³⁴

Chronic cough also increases the risk of pelvic floor dysfunction and prolapse, particularly among older women,¹³ so smoking cessation should be recommended.

Selecting the mode of delivery in a case like Marisol’s involves weighing her risks and desires with your expertise. No clear evidence is available to guide the way. This makes judicious counseling about the short-and long-term risks of conservative management and surgical delivery doubly important.

DID PRIOR DELIVERY DO DAMAGE?

Marisol’s final question concerns her first delivery. She feels she was inadequately counseled and wants to know whether delivery by cesarean would have protected her from her current symptoms.

In a prospective cohort study, Eason and colleagues⁴ found that 93.4% of women undergoing abdominal delivery remained continent postpartum, whereas 20.6% of women delivering vaginally lost urinary continence. However, Marisol’s symptoms predated the initial pregnancy.

The Term Breech Trial³⁵ found no significant differences in maternal outcomes, including incontinence and sexual function, between the planned cesarean and planned vaginal delivery groups. However, the high crossover from planned vaginal delivery to delivery by cesarean suggests this evidence should be interpreted with caution. Cesarean delivery comes with its own set of complications and long-term problems.

Counsel all women about the risks of vaginal delivery?

This is a thorny question. As the body of evidence increases on the long-term effects of pregnancy and delivery, these issues are entering the public domain. We may be approaching a time when the specter of litigation influences how we counsel women about the risks of natural childbirth. How this change will be viewed by women’s health groups—some of which already perceive the health-care system as overmedicalizing a natural event—can only be imagined.

The authors report no financial relationships relevant to this article.