Association of Delivery Mode With Pelvic Floor Disorders After Childbirth

Abstract

IMPORTANCE Pelvic floor disorders (eg, urinary incontinence), which affect approximately 25% of women in the United States, are associated with childbirth. However, little is known about the course and progression of pelvic floor disorders over time. OBJECTIVE To describe the incidence of pelvic floor disorders after childbirth and identify maternal and obstetrical characteristics associated with patterns of incidence 1 to 2 decades after delivery. DESIGN, SETTING, AND PARTICIPANTS Women were recruited from a community hospital for this cohort study 5 to 10 years after their first delivery and followed up annually for up to 9 years. Recruitment was based on mode of delivery; delivery groups were matched for age and years since first delivery. Of 4072 eligible women, 1528 enrolled between October 2008 and December 2013. Annual follow-up continued through April 2017. EXPOSURES Participants were categorized into the following mode of delivery groups: cesarean birth (cesarean deliveries only), spontaneous vaginal birth (Ն1 spontaneous vaginal delivery and no operative vaginal deliveries), or operative vaginal birth (Ն1 operative vaginal delivery). MAIN OUTCOMES AND MEASURES Stress urinary incontinence (SUI), overactive bladder (OAB), and anal incontinence (AI), defined using validated threshold scores from the Epidemiology of Prolapse and Incontinence Questionnaire, and pelvic organ prolapse (POP), measured using the Pelvic Organ Prolapse Quantification Examination. Cumulative incidences, by delivery group, were estimated using parametric methods. Hazard ratios, by exposure, were estimated using semiparametric models. RESULTS Among 1528 women (778 in the cesarean birth group, 565 in the spontaneous vaginal birth group, and 185 in the operative vaginal birth group), the median age at first delivery was 30.6 years, 1092 women (72%) were multiparous at enrollment (2887 total deliveries), and the median age at enrollment was 38.3 years. During a median follow-up of 5.1 years (7804 person-visits), there were 138 cases of SUI, 117 cases of OAB, 168 cases of AI, and 153 cases of POP. For spontaneous vaginal delivery (reference), the 15-year cumulative incidences of pelvic floor disorders after first delivery were as follows: SUI, 34.3% (95% CI, 29.9%-38.6%); OAB, 21.8% (95% CI, 17.8%-25.7%); AI, 30.6% (95% CI, 26.4%-34.9%), and POP, 30.0% (95% CI, 25.1%-34.9%). Compared with spontaneous vaginal delivery, cesarean delivery was associated with significantly lower hazard of SUI (adjusted hazard ratio [aHR], 0.46 [95% CI, 0.32-0.67]), OAB (aHR, 0.51 [95% CI, 0.34-0.76]), and POP (aHR, 0.28 [95% CI, 0.19-0.42]), while operative vaginal delivery was associated with significantly higher hazard of AI (aHR, 1.75 [95% CI, 1.14-2.68]) and POP (aHR, 1.88 [95% CI, 1.28-2.78]). Stratifying by delivery mode, the hazard ratios for POP, relative to a genital hiatus size less than or equal to 2.5 cm, were 3.0 (95% CI, 1.7-5.3) for a genital hiatus size of 3 cm and 9.0 (95% CI, 5.5-14.8) for a genital hiatus size greater than or equal to 3.5 ...

Pelvic floor muscle strength and the incidence of pelvic floor disorders after vaginal and cesarean delivery

“…For each PFD, all study participants contributed data in estimating incidence so that those who developed the PFD prior to study entry contributed to the analysis as leftcensored observations; those who developed the PFD during follow-up contributed as uncensored observations; and those who exited the study free of the disorder contributed to the analysis as right-censored observations. 16 Conventional lognormal models were used to estimate the cumulative incidence of each PFD from first delivery over time, stratified by pelvic floor muscle strength (ie, <20 cm H 2 O or 20 cm H 2 O). As delivery mode is associated with both PFDs 16 and pelvic muscle strength, 12 we further stratified based on delivery mode.…”

“…16 Conventional lognormal models were used to estimate the cumulative incidence of each PFD from first delivery over time, stratified by pelvic floor muscle strength (ie, <20 cm H 2 O or 20 cm H 2 O). As delivery mode is associated with both PFDs 16 and pelvic muscle strength, 12 we further stratified based on delivery mode. These models produced time ratios, measuring the magnitude by which times to events expand or contract relative to the reference group.…”

“…Delivery mode was also considered to be constant over time, as transitions between the vaginal and cesarean birth groups were infrequent in this population. 16 The relative hazard was estimated as a function of these fixed covariates (pelvic floor muscle strength and delivery group) and the current status of the time varying measures (BMI and genital hiatus).…”

The Onset of Urinary Incontinence in Different Subgroups and its Relation to Menopausal Status: A Hospital-based Study

“…This study showed that age at presentation and at onset of UI symptoms was significantly different in the different study groups, whereas the onset of menopause and spontaneous deliveries did not have any influence on the UI type. For spontaneous vaginal delivery, the 15-year cumulative incidence of pelvic floor disorders after first delivery have been described as 34.3% for SUI (11). Other authors described that vaginal delivery is associated with an almost two-fold increase in the risk of long-term SUI and increased risk of UUI (12).…”

Recommendations and future research initiative to optimize bladder management in pregnancy and childbirth International Consultation on Incontinence ‐ Research society 2018

“…28 For nocturia, there seems to be no difference between vaginal delivery and CS. 21,28 Most recently a study by Blomquist et al (2018) 29 reported that CS was associated with a significantly lower risk for SUI, OAB, and pelvic organ prolapse (POP) compared with vaginal delivery, while operative vaginal delivery was associated with significantly greater risk of anal incontinence and POP.…”