CURRENT STATUS

W. Donald Buie, M.D., Editor

Incidence and Etiology of Pelvic Floor Dysfunction

and Mode of Delivery: An Overview
Catherine E. Turner, M.B., B.S., M.S., F.R.A.C.S.1,2
Jane M. Young, M.B., B.S., M.P.H., Ph.D., F.A.F.P.H.M.3,4
Michael J. Solomon, M.B., Ch.B. (Hons.), M.Sc., F.R.A.C.S.1,2,3
Joanne Ludlow, M.B., Ch.B., F.R.A.N.Z.C.O.G., F.R.C.O.G., D.D.U.5
Christopher Benness, M.B.B.S., M.A., C.U., F.R.C.O.G., F.R.A.N.Z.C.O.G.5
1
2
3
4
5

Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia

Discipline of Surgery, University of Sydney, Sydney, Australia
Surgical Outcomes Research Centre (SOuRCe), Sydney South West Area Health Service, Sydney, Australia
School of Public Health, University of Sydney, Sydney, Australia
Department of Obstetrics and Gynaecology, Royal Prince Alfred Hospital, Sydney, Australia

ABSTRACT: Elective cesarean section at patient request is

becoming common place. Women are requesting the
intervention for preservation of the pelvic floor, but there
is conflicting evidence to suggest that this mode of
delivery has such benefits. The risks vs. benefits of both
vaginal delivery and cesarean section need to be well
understood before deciding on a surgical delivery. This
review outlines the current available evidence of the
risks and benefits associated with vaginal delivery and
elective cesarean section and the incidence and mechanisms
of injury that lead to pelvic floor dysfunction. As in
most surgical conditions, a better understanding of
causality of pelvic floor dysfunction may help treatment
effectiveness.
KEY WORDS: Elective cesarean section; Vaginal delivery;

Incontinence; Pelvic organ prolapse.

Dr. Turner was supported by the Notaras Fellowship of the University of Sydney, Colorectal Training Board of Colorectal Surgical
Society of Australia and New Zealand, and Royal Australasian College
of Surgeons.
Address of correspondence: Michael J. Solomon, M.B., Ch.B. (Hons.),
M.Sc., F.R.A.C.S., Royal Prince Alfred Medical Centre, 415/100
Carillon Avenue, Newtown NSW 2042, Australia. E-mail: msolomon@
med.usyd.edu.au
Dis Colon Rectum 2009; 52: 1186Y1195
DOI: 10.1007/DCR.0b013e31819f283f
BThe ASCRS 2009

1186

he debate has been extensive regarding whether the

performance of elective cesarean sections (CS) prevents pelvic floor dysfunction and other injuries. Although a randomized, controlled trial (RCT) could answer
the controversial question about whether elective CS confers improved short-term and long-term outcomes compared with vaginal delivery (VD), such a trial has never
been performed.1,2
Although VD is the physiologic mode of childbirth, it
may be associated with significant short-term and longterm complications. The prolonged pressure of the fetal
head on the pelvic floor can cause neuropraxia and there
may be direct trauma to the pelvic floor and anal sphincter complex as the fetus passes through the vaginal canal.3Y5
Pelvic floor injuries may give rise to pelvic organ prolapse (POP) and urinary and anal incontinence. There may
also be other maternal and neonatal complications associated with vaginal delivery.6Y11 The consequences can be
costly and devastating for the woman or infant,12 and medicolegal implications for the obstetrician may be involved.13
Legally and ethically patients have the right to choose
their management.14 However, if the process of vaginal
childbirth is a natural one, is it appropriate to choose
an operative intervention to bypass it without any medical
indications? Performing elective CS at patient request for
the prevention of potential complications associated with
VD is the subject of much debate. Cesarean section is not
without morbidity and mortality risks, and these factors
need to be considered when discussing CS as an alternative
option in childbirth.15 When the effects of VD are compared with those of elective CS, not only should outcomes

DISEASES

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COLON & RECTUM VOLUME 52: 6 (2009)

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of spontaneous VD be considered, but also those of assisted deliveries such as vacuum extraction and forceps
deliveries and emergency CS, because these are all potential outcomes of an attempted VD (so-called intention to
treat). Many studies exclude these modes of delivery when
measuring outcomes, thereby comparing only the outcomes of uncomplicated VD with elective CS.16
This review outlines in brief the evidence available
about the short-term and long-term outcomes of both
VD and elective CS for the mother and neonate.

ANAL INCONTINENCE
The etiology of anal incontinence following VD is multifactorial. There is a neurologic component, with pudendal nerves being stretched or injured during passage of
the fetus through the birth canal,3,4 and a muscular component where direct trauma to the pelvic floor and the
anal sphincter complex occurs.5 Debate surrounds the
relative importance of these factors in the causation of
incontinence, in the short and long term.16Y22
Vaginal delivery itself, without any evidence of sphincter injury, is associated with some degree of incontinence.
After a first, second, or third VD 1.2 percent, 1.5 percent,
and 8.3 percent of women will develop permanent flatal
incontinence.23
A cohort study of Fynes et al.24 reported that 19 percent of 200 women who had a spontaneous unassisted
VD at the National Maternity Hospital in Dublin between
June 1993 and December 1994 had fecal incontinence at
6 weeks, although 6.5 percent of these cases were flatal
incontinence only. Because outcomes were assessed at an
early stage postpartum, the reported rates of incontinence
are likely to be higher than if measured 6 to12 months
later when the reversible effects of childbirth have resolved.16Y25 Women who had instrumental deliveries (24
percent of those delivering vaginally) were excluded from
this study on the grounds that they have a higher risk of
sphincter injury and incontinence. Occult sphincter injury occurred in 33 percent of women in the sample, similar to other reports.5 No sphincter injuries occurred in
women who had CS performed at any stage.
The reported incidence of overt perineal injuries and
third and fourth degree tears has varied from 0.3 percent
to 6 percent.26Y28 Risk factors for third-degree tears are
forceps delivery (relative risk (RR) 13.3), vacuum delivery
(RR 7.4), primiparity (RR 7), birth weight of baby more
than 4,000 g (RR 2.9), and persistent occipitoposterior
position (RR 4).29Y31 Even in the absence of these risk
factors, third degree tears may still occur and are impossible to predict.29 Despite primary repair following childbirth, reported rates of persistent anal incontinence range
from 8 to 59 percent.26,28,29
Instrumental delivery has been shown repeatedly to be
associated with an increased risk of anal incontinence.30,32Y34

The adjusted relative risks of developing incontinence following forceps or vacuum-assisted delivery are 12.3 and 7.4,
respectively.30 Interestingly, however, in a case-control study
comparing vacuum vs. spontaneous VD, Peschers et al.35
found no statistically significant difference between the two
groups. Thirty percent of women in both groups had new
symptoms of anal incontinence (at least once a week). Twenty
percent of women had incontinence to flatus, 8 percent to
liquid stool, and 6 percent to solid stool. Severe incontinence, defined as that occurring more than once a week,
occurred in 10 percent, 6 percent, and 2 percent of women
for flatus, liquid stool, and solid stool, respectively.35 Incontinence rates in this study are higher than others have
reported. Criticisms of this study include the small sample
size (50 cases and 50 controls), an episiotomy rate of 92
percent in both groups (21 percent midline and 71 percent
mediolateral), and a 10 percent rate of third-degree tears.
Mazouni et al.34 reported their experience of instrumental delivery with Thierry spatulas in which 24.5 percent of women experienced new anal symptoms and 8.8
percent were incontinent to solid or liquid stool.
The long-term effect of instrumental delivery on anal
incontinence, however, has been questioned.21,36 In a longterm study with 34 years of follow-up to compare incontinence rates between women who had deliveries with or
without instruments, Bollard et al. found a nonsignificant
difference in anal incontinence between the two groups.36
Although 44 percent of women who had forceps delivery
had a sphincter injury, compared with 22 percent among
those who had an unassisted VD, the rate of incontinence
in these groups was 14 percent and 10 percent, respectively.
The investigators acknowledged that the study was underpowered to show significant difference, but concluded that
aging may be a more important factor affecting continence
in the long term. Abramov et al.21 came to similar conclusions when comparing anal incontinence in identical twin
sisters. Among 271 pairs of sisters, mode of delivery, including instrumentation, was not found to be a significant risk
factor for anal incontinence. Menopause, body mass index
greater than 30, parity greater than 2, and stress urinary
incontinence (SUI) were the only significant risk factors for
development of anal incontinence in the group studied.21
Episiotomies may be associated with an increased risk
of sphincter injury and incontinence.25,31 There is an increased chance of developing a third-degree or fourthdegree tear after a midline episiotomy (odds ratio (OR) 2.24,
P G 0.001), but a posterolateral incision may be protective
(OR 0.67, P = 0.017).31
Signorello et al.,25 in their cohort study, showed that
midline episiotomy was an independent risk factor for anal
incontinence, with double the rates compared with women
who had spontaneous tears. At three months, 8.8 percent
of women with a nonextending midline episiotomy were
fecally incontinent, compared with 2.4 to 4 percent of
those with intact perineum, or tears (ranging from second

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to fourth degree).25 These rates of incontinence decreased

to 4.3 percent and 1.5 to 2 percent, respectively, six months
postpartum. The rate of flatal incontinence for the episiotomy group was nearly 30 percent and 20 percent at three
and six months, compared with nearly 20 percent and 10
percent for the group with intact perineum and other
spontaneous tears.25 In this cohort, episiotomy was used
selectively rather than routinely. Interestingly, this study
demonstrated that incontinence decreased with time, so
measurement at three months may be misleading. Routine
episiotomy has been abandoned in many countries because
evidence has shown that it is more harmful than beneficial.37
Birth weight of more than 4,000 g has been implicated in the etiology of anal incontinence by some investigators,29,31 but not by others.30 It has been associated
with an increased risk of developing a sphincter injury
(OR 2.19, P G 0.001).31
Subclinical or occult sphincter injuries were described
by Sultan et al.5 in 1993. With the use of endoanal ultrasonography, 35.4 percent of 79 primiparas and 43.8 percent of 48 multiparas were shown to have sphincter defects
following VD, with all defects persisting at six months
follow-up.5 Six weeks postpartum, one third of these patients were symptomatic (10 percent of the total group);
20 percent had anal incontinence, and 37 percent had fecal
urgency. Only one woman without a sphincter defect (1.3
percent) had temporary anal incontinence. At six months
follow-up, the symptoms of some women had improved or
resolved, and a few had new symptoms, but only 65 percent
of women returned for follow-up. External sphincter injuries occurred only with injuries to the perineum, but internal sphincter injuries were present with an intact perineum,
and were more common in women with shorter anal canals.5
Since this study, four other large studies have been
published on sphincter injuries confirmed by endoanal
ultrasonography.38Y41 A meta-analysis of these five studies
revealed that the incidence of occult sphincter injuries in
primiparous women was 26.9 percent and the incidence
of new injuries in multiparous women was 8.5 percent.42
Thirty percent of women with sphincter injuries had symptoms of fecal incontinence. Of note, symptoms of fecal
urgency were excluded from this analysis.42
Andrews et al.43 suggested that occult injuries may
in fact be missed injuries. In their study, women were
reexamined following their delivery by a trained research
fellow, which increased the diagnosis of sphincter injuries from 11 percent to 24 percent. They recommended
improvements in training of perineal anatomy and recognition of obstetric anal sphincter defects, to improve
incontinence outcomes following childbirth.
The long-term significance of clinically evident and occult sphincter defects is unknown. In a 30-year retrospective
review, anal incontinence was compared in women with
sphincter injuries, episiotomies, and cesarean section.44
There was a significant difference between the groups in

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rates of bothersome flatal incontinence and frequent fecal

incontinence.44 In another study, Damon et al.18 followed
up women six years after their first VD, at which time
33.5 percent were found to have occult sphincter injuries.
At 12 weeks, 10 percent of all women had symptoms of
incontinence, 22 percent of those with proven injuries
and 4.5 percent without. Six years later, there was a 50
percent rate of incontinence in those with sphincter injuries, compared with 8.1 percent in those without.18 It
has been suggested that sphincter injuries may go on to
become symptomatic later in life.45 Factors such as age
and disease may influence the healed injury, and alter the
bodys ability to compensate for it, which may lead to
incontinence in the elderly.45
There is also a neurologic component to anal incontinence but it is unclear whether this is the result of
pregnancy, or of VD. Investigators have shown that CS
late in labor can lead to pudendal nerve injuries.20,24
Fynes et al.24 showed that pudendal nerve terminal motor
latencies (PNTMLs) were increased with labor in the CS
group, more so if they had CS in late labor compared
with early labor. They concluded that labor itself can
cause neuropathy, so only elective CS before labor, or at
an early stage in labor, would prevent neuropathy. This is
consistent with the findings of Allen et al.3 who showed
no change in nerve conduction studies on the pudendal
nerve, between antenatal and postnatal measurements in
women who had CS before labor. Those who had CS during labor had increased motor unit potential durations in
their concentric needle electromyography (EMG) studies.3
The question arises: can fecal incontinence be prevented by CS, and is it worth the other risks associated
with the surgical intervention? In a recent systematic review to assess the efficacy of CS to prevent anal incontinence, Nelson et al.16 concluded that CS does not prevent
anal incontinence, and that other factors are implicated in
its development. They calculated 167 women would need
to undergo CS to prevent one case of anal incontinence,
and 402 to prevent flatal incontinence (because flatal incontinence was seen following CS). One flaw of this review, however, was the exclusion of all women who had
instrumental deliveries that are associated with greater
risks of incontinence, which would bias the results of the
review in favor of spontaneous VD.
The importance of anal incontinence as a concern
among pregnant women was highlighted recently in a
study undertaken by our group. Of 18 potential complications of VD, primiparous women (n = 122) and clinicians (n = 341) alike were least accepting of the risk of
anal incontinence.46

URINARY INCONTINENCE
There is debate in the gynecologic community about the
effects of mode of delivery on the rate of urinary

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incontinence, but some still dispute the association of

urinary incontinence and pregnancy itself.
In a sample of 484 primiparous women in Nova Scotia,
Canada, Farrell et al.47 found that, at six months postpartum, the overall incidence of urinary incontinence was
26 percent. Four percent of women were considered to
have clinically significant, incontinence, defined as a daily
episode of loss of urine. The rate of incontinence in the
CS group was 10 percent (elective and nonelective were not
significantly different); in those with spontaneous VD, the
incontinence rate was 22 percent, and in women who had
forceps deliveries, it was 33 percent. The relative risk of
incontinence following spontaneous VD compared with
elective CS was 2.1.47 They also showed that women with
incontinence before pregnancy were nearly three times
more likely to have postpartum incontinence.47
Groutz et al.48 studied SUI in primiparous women
one year postpartum. Incontinence was defined as regular if it occurred twice or more a month. They found a
nonsignificant difference in rates of SUI after spontaneous VD and women having CS for obstructed labor (10.3
percent vs. 12 percent, P = 0.7). In comparison, only 3.4
percent of women who underwent elective CS before labor had SUI (P G 0.05). Approximately half of the patients
rated their SUI as moderate to severe. In all groups, SUI
in pregnancy was a significant predictor for postpartum
incontinence. Womens weight and duration of labor were
also significantly associated with development of SUI.48
Instrumental delivery was an exclusion criterion in this
study; thus, rates of SUI among all women who had VD
(unassisted or instrumental) could have been higher.
A large community-based cohort study (EPINCOT),49
from a county in Norway between 1995 and 1997 included
15,307 women between 20 and 65 years of age who were
either nulliparous, had only had CS or only had VD. It
showed that the prevalence of any incontinence was 10.1
percent in nulliparous women (who had never given birth),
15.9 percent in those following cesarean section only (no
difference between elective and emergency cesarean), and 21
percent in women following VD only.49 These differences
were seen in the total population, and in women between
20 and 39 years of age. In the older age group (50-year-old
to 64-year-old women), there was no difference in
incontinence rates between those who had caesarean and
VD, 28.6 percent and 30 percent, respectively. In contrast to
this, nulliparous women in this older age group had a
prevalence of 15.2 percent. The authors argued that a very
large increase in CS would have to occur to decrease the rate
of incontinence by 5 to 10 percent and this would only be of
benefit until women reach 50 years of age, because after this
time, the prevalence of SUI is the same regardless of mode
of delivery.49
Similar findings were shown by MacArthur et al.50 in
a large longitudinal cohort study of all women who delivered in three maternity units in Scotland, England, and

New Zealand between 1993 and 1994. Urinary symptoms

were ascertained for 4,214 women three months and six
years after their index delivery. Women who only delivered by CS had half the risk of developing incontinence
compared with those who had any other mode of delivery
(14.3 percent vs. 26.3 percent, OR O.46, P G 0.001). Instrumental delivery (forceps or vacuum) was not associated with an increased rate of UI compared with VD,
similar to findings of other investigators.35 Other factors
associated with an increased incidence of UI were increasing age (over 35 years) for the index delivery, three or more
births, and prepregnancy body mass index greater than 25.
No conclusions can be made from this study regarding the
effect of mode of delivery on urinary incontinence in the
postmenopausal period. Only 5 percent of the women studied had their index delivery when they were over the age of
35; so even after six years follow-up only a small percent of
these women would have been in early menopause.50
Mode of delivery as a risk factor for UI was also
evident in the Evanston-Northwestern Twin Sisters Study
which demonstrated that the likelihood of UI developing after VD was 2.28 times higher than for CS, at least
in younger women.21 The mean age of the women who
participated in this study was 47 years.
In the postmenopausal period, factors other than
mode of delivery may be more significant in influencing
UI.49,51,52 Buchsbaum et al.52 studied groups of postmenopausal parous and nulliparous sisters, finding no differences in rates of UI. They concluded that there may be a
familial predisposition toward development of incontinence. Another study on a cohort of nulliparous postmenopausal nuns found that they had similar rates of UI
to parous, postmenopausal women.51
An epidemiologic study carried out in South Australia showed a strong association between pelvic floor
disorders and pregnancy, parity, and instrumental delivery, but did not show a significant reduction in incidence
in those women who had cesarean (elective, or performed
in labor) rather than VD.53 The authors suggested it was
parity rather than the mode of delivery that caused damage in the long term.
When discussing urinary (and to some extent anal)
incontinence, it is important to point out that many maternity units stress the importance of pelvic floor or Kegel
exercises as a method to prevent or treat these problems in
both the antenatal and postnatal period. The effectiveness
of these exercises has been debated with many studies
having only a short follow-up period.54Y57 A large multicenter RCT showed that at one-year postpartum, there was
a lower rate of UI in the pelvic floor exercise group (60
percent vs. 68 percent, P = 0.037), and a lower rate of anal
incontinence (4 percent vs. 11 percent , P = 0.012).58 At six
years, however, there was no difference between the groups.
The main criticism of the study is that pelvic floor exercises were generally not carried out long term.

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PELVIC ORGAN PROLAPSE

Pelvic organs are kept in place by the endopelvic fascia,
and the levator ani muscles closing the pelvic floor.59 Relaxation or damage to the pelvic floor may result in uterine prolapse, rectocele, cystocele, or enterocele. The etiology
of POP is thought to be multifactorial. Risk factors include VD, pregnancy, age, genetic factors, hypoestrogenism, trauma, musculoskeletal diseases, chronic diseases,
smoking, and prior surgery.60
Vaginal delivery is considered the strongest risk factor
for POP. The etiology of pelvic floor muscle damage related to VD is similar to that which leads to anal incontinence, both neurogenic and/or myogenic.61 Similar
conclusions may be made about the role of prevention of
POP with CS performed before labor or in the early
stages. In considering neurogenic and myogenic effects on
the pelvic floor, Dietz showed that full engagement of the
fetal head and duration of the second stage of labor have
significant effects on levator function, and CS in the second stage is not protective of these changes.62
The Pelvic Organ Support Study (POSST) showed that
each VD increased the risk of prolapse by 1.2 times.63
Similarly, another group of investigators showed that women
with two VDs had 8.4 times the risk of developing prolapse,64 and a Turkish study demonstrated an almost 12-fold
increase in risk in women with four or more VDs.65

SEXUAL DYSFUNCTION
Sexual dysfunction or dyspareunia may occur after childbirth. It usually returns to normal within six months of
the birth, but it may take longer in patients following complicated instrumental deliveries.66
Buhling et al.67 surveyed 655 women regarding their
sexuality postpartum. Forty-seven percent resumed intercourse within 8 weeks and 46 percent experienced significant dyspareunia during first intercourse. Persistence of
dyspareunia for longer than six months was greater in
women with episiotomies or lacerations (10 percent) and
operative vaginal deliveries (14 percent), compared with
3.4 percent of women with unassisted VD and CS.67
Other groups have reported higher rates of dyspareunia of
approximately 20 percent at six months following vaginal birth,68,69 with a trend toward higher rates in women
with deeper tears compared with those with an intact
perineum. The West Berkshire Perineal Management Randomised Controlled Trial of liberal vs. restricted use of
episiotomy showed no significant difference in postpartum dyspareunia in either group.70 Perineal massage during pregnancy has also been shown to have no effect on
outcomes of sexual function postpartum.71
The role of CS in preventing sexual dysfunction postpartum has been questioned. Barrett et al.72 studied 484
women, 25 percent who had delivered by CS. At three

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months, there was a lower rate of dyspareunia in the CS

group, compared with those who delivered by vaginal birth,
but the difference was no longer present at six months.
There were no significant differences between those who
had elective vs. emergency CS.
In summary, VD has been implicated in the etiology
of pelvic floor dysfunction, although the evidence of the
long-term effects is more questionable. If this is so, should
there be a move toward elective CS to prevent the potential
effects of delivery on the pelvic floor? The potential risks of
elective CS should be counterbalanced in this debate.

POTENTIAL COMPLICATIONS ASSOCIATED WITH

CESAREAN SECTION
Cesarean section may be associated with increased shortterm morbidity and mortality compared with VD, and may
also have serious consequences for subsequent reproductive life and health.73 Cesarean section is also more costly
to perform. All these factors need to be considered in the
risk-benefit equation when comparing normal VD and
elective CS.74
Maternal mortality is rare in Western countries. The
most recent rates for the United Kingdom and Australia
are 11.4/100,00075 and 8.2/100,000,76 respectively, with
the relative risk of death associated with CS being 2.0.75
Other reports also show a higher incidence of maternal
mortality in CS.10,11 Lydon-Rochelle et al.11 found that
maternal mortality was 2.84 times more common after
elective CS and 8.84 times higher for emergency CS when
it was compared with VD. In France, maternal death following CS has been reported to be 5 to 25 times more
common compared with vaginal delivery,10 but it must be
noted that these figures include both elective and emergency CS, and the data are old (years, 1970 to 1980).10 In
contrast with these studies, the Term Breech Trial showed
no difference in mortality and serious short-term morbidity between the elective CS and the trial of labor group.77
Complications requiring hospital readmission are reportedly more common after CS,11,78 but there is often no
differentiation in these studies between elective and emergency CS. Some of these complications include thromboembolic and cardiopulmonary disease, wound complications,
and endometritis. The risk of deep venous thrombosis following operative delivery is thought to be higher than following VD, but recent evidence suggests that low-risk
elective CS may not have an increased risk.79 Koroukian
et al.80 reported on postpartum morbidity following elective or emergency CS or VD (assisted and spontaneous
combined). Compared with VD, elective CS had a higher
relative risk of major puerperal infection (2.87 vs. 0.94),
and a higher rate of thromboembolic events (0.19 vs. 0.08),
but a lower rate of postpartum hemorrhage and transfusion requirements, and the expected lower incidence of
obstetric trauma.80

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Long-term reproductive consequences also need to

be considered. After a CS, future pregnancies and deliveries may be at an increased risk of complications. The
risk of uterine rupture is increased. Trial of vaginal birth
after CS is associated with an increased rate of uterine
rupture and its consequences, compared with repeat CS,
and also compared with repeat VD.81A large multicenter
observational study that compared a trial of VD with repeat CS showed that the rupture rate was 0.7 percent,
hypoxic ischemic encephalopathy was significantly higher
in the trial of the labor group (0.45 per 1,000 vs. none in
CS group) and the rate of rupture-related neonatal deaths
was 0.11 per 1,000.81
Multiple CS are associated with increased maternal
morbidity,82Y84 complications include intra-abdominal
adhesions, bladder, bowel and ureteric injuries, increased
blood transfusion requirements, admissions to intensive
care units, and increased length of stay. One of the most
significant consequences is the increased incidence of placenta previa and accreta and the need for hysterectomy.
Placenta previa (low-lying placenta, close to or over
the internal opening of the cervix) may cause antenatal,
intrapartum, or postpartum bleeding, and may lead to
peripartum hysterectomy.85 The relative risk of placenta
previa developing in the second pregnancy following a CS
compared with a previous normal VD is 1.5 and increases
to 2.0 following two previous CS, compared with two
previous vaginal deliveries.86 Maternal mortality in the
United States occurs in 0.03 percent of cases with placenta previa.85
The rate of placenta accreta (placenta abnormally adherent to the uterus) increases with each subsequent CS.
The rate during a first, second, third, fourth, fifth, or sixth
or more CS is 0.24 percent, 0.31 percent, 0.57 percent,
2.31 percent, 2.33 percent, and 6.74 percent, respectively.82
This condition may be serious, with mortality reported as
high as 7 percent.87 Urgent hysterectomy is usually required,
and there may be massive blood losses leading to disseminated intravascular coagulation, with all its sequelae.82
Cesarean section scar ectopic pregnancy refers to a
pregnancy located outside the uterine cavity, within the
wall of the uterus. This abnormality is a potential complication of a previous CS,88 and although it is uncommon,
it may be catastrophic leading to uterine rupture and profuse hemorrhage as the pregnancy advances.
Psychologic effects such as maternal-neonatal bonding or interaction and the experience of childbirth are
often quoted as negative consequences of CS. There is
also concern that breastfeeding is delayed following CS.
In 1983, Tamminen et al.89 examined the effect of various perinatal factors on breastfeeding among 1,701 women.
Those who delivered by CS or assisted delivery were found
to be less likely to commence breastfeeding, but this occurred in only 2.4 percent of the sample.89 Delay in breastfeeding may occur following CS, but this does not affect

rates of breastfeeding.90 Three months after delivery, 1,596

(82.3 percent) women who participated in the International
Randomised Term Breech Trial completed questionnaires
regarding many psychosocial and physical outcomes associated with childbirth.90 This was a RCT in which pregnant
women were allocated to deliver either by VD or elective
CS if they had a breech presentation at term.90 Fewer
women in the CS group breastfed within a few hours of
birth (73.3 percent, compared with 77.6 percent in the VD
group; RR 0.94; confidence interval (CI) 0.89 to 1.0; P =
0.05); however, there was no difference between groups in
the proportion of women who initiated breastfeeding (88.4
percent), and who were still breastfeeding at three months
(68.6 percent). This study also showed no difference in
rates of postnatal depression or level of satisfaction women
had with their mode of delivery.90 The two-year follow-up
of these women showed similar findings.77
Schindl et al.91 conducted a prospective trial involving 1,050 women who completed questionnaires at 38
weeks gestation and Day 3 and 4 months postpartum to
ascertain psychologic factors, pain levels, and their experiences of birth. Results were compared between 903
women with a planned VD, 41 (4.5 percent) who required a vacuum-assisted delivery, 93 (10.3 percent) who
underwent emergency CS, and 147 who had an elective
CS. Women who had elective CS scored higher in their
birthing experience than those with a vaginal delivery,
whereas those with emergency CS and assisted deliveries
scored the worst.91
Method of delivery and parent-newborn interaction
was also investigated by Kochanevich-Wallace et al.,92
who found no association between mode of delivery,
either vaginal or cesarean section, and the bonding process. Similarly, the Term Breech Trial found that maternal
relationship with the child (or the husband or partner) was
unrelated to mode of delivery.77,90
When discussing the potential complications of different childbirth options, one must take into account the
neonate. Neonatal complications may be associated with
childbirth.
Shoulder dystocia, intracranial hemorrhage, and neonatal hypoxemic encephalopathy are rare, but serious potential complications of a complicated VD.6,93,94
The incidence of intracranial hemorrhage is very low,
approximately 5 of 10,000 live births; these rates are similar in uncomplicated vaginal births and elective CS, but
are more than doubled in emergency CS and operative
vaginal deliveries.95 The incidence of hypoxemic ischemic
encephalopathy (HIE) is 3.8 of 1,000 term live births.96
Although it has been shown that intrapartum factors
account for only 30 percent of these cases, the risk of HIE
developing after a VD may be 20 times higher than after
an elective CS.96 However, the need for resuscitation following delivery, and ongoing need of intensive or intermediate care during hospitalization is higher for CS (elective

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or emergency), when compared with an uncomplicated

VD.7,97 It must be noted that the increase in respiratory
distress syndrome (RDS) and transient tachypnea documented in CS is mostly associated with CS performed
before term, with the rates being similar to VD when CS is
performed from 39 weeks onward.98,99
As there are many variables in the outcomes of an
attempted vaginal delivery, Mac Dorman et al.100 utilized
an intention-to-treat model to analyze the neonatal
mortality for primary cesarean and VD in low-risk
women. In the most conservative model they used with
adjusted odds ratios, they estimated a relative risk of
neonatal mortality to be 1.69 for those born by elective
CS compared with planned VD.

2.

3.

4.

5.

6.
7.

CONCLUSION
The overall balance of risks and benefits of vaginal delivery compared with elective cesarean section is difficult
to determine, although on current evidence it appears
that vaginal delivery is the safest mode of delivery for the
vast majority of women. Until an RCT comparing the
outcomes of each mode of delivery is performed,1,14 decisions about which is the best option for individual
women must be based on the current imperfect evidence
base and the level of risk of complications that individuals
are willing to take.60 Our research has suggested that only
14 percent of primiparous women would enter a RCT,
which is likely to threaten the feasibility of such a trial.101
Husslein and Wertaschnigg proposed that, in keeping
with the greater importance currently being assigned to
patients preferences, the authors support the view that
the parturient herself should be enabled to decide what
level of risk is acceptable to her, including stating her
preference for a delivery by cesarean sectionIin this
context, comprehensive information and rigorous documentation are indispensable requirements.102 We agree
that pregnant women have the right to informed consent
when deciding on their mode of delivery, but this consent
differs from any other surgical procedure; there is not an
option of no treatment if she is unwilling to accept risks,
the baby has to be delivered in one way or another. Not
all women will have the capacity to understand the complexity of potential outcomes, and how to weigh both
maternal and neonatal risks. Much anxiety may be caused
by even attempting to explain some of the potential outcomes discussed in this article, in particular, when some
of the evidence, such as that for pelvic floor dysfunction,
is inconclusive, especially in the long term.

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