Vaginal or Caesarean? It’s UR CHOICE….

22 Mar Vaginal or Caesarean? It’s UR CHOICE….

Black and white shot of newborn baby right after delivery

It is often debated, and people often feel very strongly one way or the other. I have long been an advocate that it is the choice of the mother alone, and well meaning (or perhaps not so well meaning) family members and friends should be careful with their comments to the pregnant ladies in their lives.

You should not have to justify your choice to anyone, so someone commenting on your choice of how you deliver your baby, is really just none of their business.

I am often asked by patients and friends, who had traumatic first deliveries and are now experiencing pelvic floor dysfunction, what they should do the second time around.

Or also by women who are currently pregnant with their first child and worried about the risks of delivery (both vaginally or via caesarean), wondering what would be the best choice for them.

The International Urognaecology Journal recently published an article discussing whether pelvic floor dysfunction resulting from vaginal delivery could be something that is able to be predicted in advance.

This would mean we could give more information to women before making their choice, and reassure women who are low risk for pelvic floor problems that vaginal delivery should be a safe bet for them.

The article was written after a reported heated discussion in at an IUGA (International Urogynaecological Association) meeting, where it was discussed if instrumental delivery (forceps and vacuum) should be abandoned in favour of Casesarean section.

This discussion would have been prompted by the fact that we now know that forceps in particular, significantly increases the risk pelvic floor disorders (incontinence and prolapse). Yet, the push for caesarean rates to be low in hospitals, might mean the Obstetrician is more inclined to reach for the forceps rather than the scalpel when things are going pear shaped.

I had a patient who saw me when she was home from Switzerland who told me that in Switzerland, they don’t do Forceps deliveries at all. They will go to Caesarean instead. Given that the use of forceps significantly increases the chance of pelvic floor damage, I think this is worth consideration.

The authors of this particular research are now looking into whether we can predict pelvic floor damage in advance, and forewarn women as to where they sit on a risk scale to better enable them to make the decision of vaginal versus caesarean.

Caesarean section has been shown to decrease the chance of developing a prolapse (especially if the woman has caesareans exclusively), and to a lessor extent, is somewhat protective against incontinence.

However, caesareans are not risk free themselves. The risk of surgery itself; infection, blood loss, pain, and a more difficult recovery, as well as repeat caesareans increasing the risk of placenta previa and accreta.

It is never an easy “choice” for anyone.

In this particular paper, the authors have proposed a scoring system (titled UR CHOICE) to predict the risk of future pelvic floor dysfunction based on several major identifed risk factors.

These are:

U – Stands for Urinary incontinence, but faecal incontinence should also be considered. Was there incontinence before pregnancy?

R – Stands for race. Asian women have a higher risk of sustained a third or fourth degree tear.

C – Childbearing was started at what age?

H – Height of the mother is less than 160cm.

O – Overweight (BMI of the mother).

I – Inheritance (family history of pelvic floor problems, mother and sisters particularly)

C –Children (how many children are they planning to have). This is significant because if you are considering more then 2 pregnancies, the risk of having all caesareans outweighs the risk of pelvic floor dysfunction.

E- estimated fetal weight is more than 4kg

In the coming months they will be putting together a scoring system utilizing each risk factor to provide an antenatal pelvic floor trauma predictive score, so that all mothers could be informed of realistic expected outcomes.

A low score will reassure mothers wanting a vaginal delivery, or inform mothers considering an elective caesarean that their risk of pelvic floor complications are low. Pelvic floor strength should still be assessed post-natally and a pelvic floor muscle exercise program given.

A mid range score would indicate a referral for pelvic floor physiotherapy antenatally and postnatally for pelvic floor exercise training.

A high score would indicate a pelvic floor physiotherapy referral, antenatally, postnatally and annually. Depending on how she feels about caesarean section, and the number of children she desires (if she wants 3 or more children increased risks of repeat surgeries outweigh any pelvic floor benefits), the women may choose to opt for a C/section. Or plan to go to a c/section early in labour if there are any signs of obstruction.

If this scoring system was to be used, it should help to empower women when making their own choice about their own delivery.

Although risk factors have been identified, also of interest, was a recent study published by Miller et al (2015) in the Midwifery journal, which looked at factors that contributed to a “normal” (I do loathe the use of the word ‘normal’ to describe childbirth), but in this case they are referring to no induction, drug free, instrument and surgery free childbirth, and it was done in Queensland.

They found about 30% were ‘normal’, and that the chance of having a ‘normal’ birth was increased by giving birth in a public hospital, outside of business hours, where women were able to be ‘mobile’ during their labour, did not have constant fetal monitoring and were not lying down during delivery.

So my question is, could the risk factors be counteracted at all by the circumstances of giving birth? Personally, I would like to see some research on this in the future.

I generally find that knowledge is power and anything we can do to better inform women of any risk factors that they might have is a good thing. Personally, I am looking forward to see what they develop.

References:
Wilson et al. (2014) UR- CHOICE: can we provide mothers-to-be with information about the risk of future pelvic floor dysfunction? Urogynecol J 25:1449–1452 

Miller et al. (2015) Back to normal: A retrospective, cross-sectional study of the multi-factorial determinants of normal birth in Queensland, Australia. Midwifery 31 (8),pp 818–827[/vc_column_text][/vc_column][/vc_row]

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