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Women want to know risks, benefits of elective cesarean.

YOSEMITE, CALIF. -- One of the main reasons women may want a primary elective cesarean delivery is to protect the pelvic floor from injury leading to urinary and fecal incontinence, but they need to know that current evidence suggests it will not prevent every such case, Dr. Washington C. Hill said at a meeting on obstetrics and gynecology sponsored by Symposia Medicus.

The practice of primary elective cesarean has been established and the demand for it is likely to grow. Therefore, physicians need to be able to counsel women on the associated risks and benefits, said Dr. Hill, director of maternal-fetal medicine at Sarasota (Fla.) Memorial Hospital.

"If you have not had someone ask you about this yet, you will," he said.

Dr. Hill reviewed the literature about those risks and benefits, for the woman and the fetus.

The potential benefits to the woman include avoiding an emergency cesarean, with its potential complications, and avoiding the possibility of pudendal nerve injury if forceps must be used. The most important long-term benefit, however, is potential pelvic floor protection, Dr. Hill said.

Evidence suggests that pelvic floor disorders, specifically stress urinary incontinence, occur in about 25% of women post partum, but that most cases do not persist for more than 3 months. On the other hand, an estimated 11% of all women have at least one operation for pelvic organ prolapse or urinary incontinence during their lifetime.

The only study that prospectively evaluated stress urinary incontinence following planned cesarean versus vaginal delivery indicated that even with a planned cesarean--that is, no labor--incontinence still occurred in 5% of the women. The study was a survey taken 3 months post partum of 1,596 women who had singleton fetuses in a breech presentation at term. Seven percent of the women reported stress urinary incontinence after vaginal delivery (JAMA 287[14]:1822-31, 2002).

Dr. Hill tells patients that elective cesarean reduces the rate of stress incontinence from 10% to 5%.

The potential benefits to the fetus are exceedingly small because adverse events affecting the fetus are rare, Dr. Hill said. In fact, it's arguable whether one can claim there is any benefit to the fetus at all.

The critical risk to consider is that of maternal mortality, because that is the worst possible outcome. Most experts believe the risk of mortality with an elective cesarean is now equivalent to that of vaginal delivery (N. Engl. J. Med. 348[10]:946-50, 2003).

A different report from the same group that studied urinary incontinence after planned cesarean found that maternal mortality and serious maternal morbidity were the same, about 3% (Lancet 356[9239]:1375-83, 2000).

When informing a patient about the risks of cesarean to the woman, physicians should not forget to mention that a history of cesarean section will increase the risk of uterine rupture and placenta previa in subsequent pregnancies.

Regarding risk to the fetus from an elective cesarean, Dr. Hill noted that if the due date is wrong, and the infant is delivered too early, there is the risk of respiratory distress syndrome, and there is always the possibility that the fetus may get nicked by the scalpel or otherwise injured.

Infant mortality with elective cesarean is unknown, Dr. Hill said. The risk of infant mortality with a primary cesarean is 12/1,000 births and the risk with a repeat cesarean is 6.4/1,000 births, but those estimates include both planned and unplanned cesareans. The risk of infant mortality with vaginal delivery is 6.5/1,000 births.

Taken as a whole, the evidence does not support the idea that one can make any definite recommendations to patients regarding elective cesarean, beyond the fact that it will not be appropriate for every patient, Dr. Hill said. But it does suggest that, for an informed patient, elective cesarean should be an option.

He suggested that physicians who are not comfortable performing a primary elective cesarean refer such patients to someone who is, rather than trying to dissuade them. "However you feel about it, women are going to present this question to us," Dr. Hill concluded.
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Title Annotation:Women's Health
Author:Kirn, Timothy F.
Publication:Family Practice News
Geographic Code:1USA
Date:Sep 1, 2004
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