Do C-Sections Reduce Your Risk of Pelvic Floor Disorder?

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Recently, I overheard a stroller fitness instructor remind all new moms in her class to kegel, whether they had had a c-section or vaginal birth. She said the type of birth didn’t matter because “most of the damage happens during pregnancy and not delivery.” I’m a fan of the kegel, but does most pelvic floor damage really happen during pregnancy rather than delivery? Really?

Of course not. What a silly thing to say.

I’ve run across this myth many times. Why is it repeated so often? Is it to discourage unnecessary c-sections? To perpetuate the image of vaginal birth as inherently without risk? To make us feel better about our births because pregnancy did us in? Honestly, I have no idea.

Let’s be clear: C-sections do not guarantee you will not have pelvic floor disorder. Vaginal births do not guarantee you will have pelvic floor disorder. That’s not how any of this works. Nonetheless, pushing (and attempting to push) a baby through your vagina is different than cutting one out through your abdomen, a difference that leads to higher rates of pelvic floor disorder for the former. Duh.

I’ve done both the cutting and pushing versions of childbirth, and each has its advantages and disadvantages. C-sections have obvious surgical risks that shouldn’t be understated, and vaginal birth can carry its own repercussions. Neither one makes you less of a mother or reflects on you positively or negatively as a person. This is not a post about the superiority of how one gives birth, nor is this a post meant to encourage c-sections because vaginal births will ruin your vagina. Let me reiterate, having a c-section does not mean your pelvic floor is forever safe from a disorder and giving birth vaginally does not mean your pelvic floor is forever ruined.

Now that I’ve got the disclaimers out the way, let’s tackle the data and this misperception that pregnancy causes pelvic floor disorder independent of how you get that baby into the world.

The Studies

We have some pretty good studies looking at the role of vaginal and cesarean delivery on the development of pelvic floor disorder. This topic is harder to study than you would think because PFD (pelvic floor disorder) often develops over time, has varied etiologies, and can be hard to quantify and study. How do we know someone’s PFD resulted from childbirth and not from other lifestyle or genetic factors? Furthermore, a combination of delivery method, lifestyle, and genetics often influences the presentation of symptoms. This is why the totality of the evidence is important, not just a few cherry picked studies.

And the totality of the evidence shows…vaginal delivery increases the risk of PFD compared to cesarean delivery. This is wholly unsurprising, but sometimes studies need to find unsurprising results over and over to confirm common sense (and yet somehow this unsurprising evidence does not filter down to stroller fitness instructors, go figure).

Here is a sampling of the studies:

A. “Cesarean section: does it really prevent the development of postpartum stress urinary incontinence? A prospective study of 363 women one year after their first delivery.” 2004

This study was prospective, which means women were recruited immediately after delivery and followed for a year. A year isn’t a ton of time, but prospective studies are more helpful than retrospective examinations that look back in time with all the biases of the present. The study looked specifically at stress urinary incontinence, rather than a wider range of pelvic floor disorders (like pelvic organ prolapse).

What did they find? Rates of postpartum SUI were similar after vaginal delivery and c-sections performed for obstructed labor. Conversely, c-sections performed without a trial of labor (usually elective c-sections) were associated with significantly lower rates of SUI.

This is an interesting finding. The labor, not just the delivery, affected rates of SUI (again we don’t know about prolapse). Nonetheless, pregnancy itself wasn’t the prime mover, otherwise we would have expected to see no affect on SUI from elective c-sections. Ergo, pregnancy is NOT the primary cause of postpartum incontinence.

B. “Role of different childbirth strategies on pelvic organ prolapse and stress urinary incontinence: a prospective study.” 2008

Another prospective study, this time looking at the first couple months post delivery and specifically addressing prolapse. They found that “the prevalence of POP is significantly higher after vaginal delivery than after cesarean delivery.”

C. “Association between mode of delivery and pelvic floor dysfunction.” 2014 Review

This review found that “the prevalence of urinary incontinence and pelvic organ prolapse is lower in women who have only delivered by caesarean section than in those who have delivered vaginally.” However, the reviewers also noted that this difference starts to level out as women age, meaning childbirth isn’t the only cause of urinary incontinence for older women. They note that c-sections will not solve pelvic floor dysfunction “at a population level.”

This last line is important because the point of these studies is not to suggest all women have c-sections to prevent all PFD. That said, on an individual level, c-sections should absolutely be a choice if your medical and birthing history warrants it.

D. “Pelvic floor dysfunction after vaginal and cesarean delivery among singleton primiparas.” 2017

This is a recent study that looked at women 5–10 years after delivering a baby.

Significant differences in the occurrence of symptoms of UI were observed after vaginal delivery as compared with cesarean delivery.

Are you noticing a trend?

E. “Predicting risk of pelvic floor disorders 12 and 20 years after delivery.” 2017

Finally a study that tested actual models for predicting who will get pelvic floor disorder. Their finding: “Route of delivery and family history of each pelvic floor disorder were strong predictors in most models.”

Delivery, Not Pregnancy Plays the Largest Role in Pelvic Floor Disorder

I wonder if proponents of the “pregnancy, not delivery” causes pelvic floor disorder have latched onto population stats showing that rates of PFD increase as women age, thereby assuming childbirth is unrelated to rates of incontinence and prolapse. This reasoning overlooks the actual evidence proving that mode of delivery has a large effect in the immediate postpartum period and some years afterwards, especially on an individual level when combined with specific childbirth injuries not amenable to kegels or other conservative interventions.

Instead of perpetuating misinformation and painting childbirth with a broad brush, we should spend more time testing the accuracy of models that predict certain forms of pelvic floor disorder. Reliable models could cut down on the number of unnecessary c-sections AND the number of dangerous vaginal births. Women deserve to know their individual risk factors. Unfortunately, it’s still a crapshoot because we don’t have amazing predictive models. Personally, I had to endure two dangerous vaginal births before having an elective c-section. On the other side, I know women who felt pressured into a c-section by overly cautious doctors.

I’m hopeful for future generations that we will stop the silly birthing wars and instead focus on fine-tuning the evidence base. This is the main reason I pushback against misinformation that filters into the momosphere, misinformation that not only comes from stroller class instructors, but often from physical therapists and personal trainers who should know better. Women aren’t helped by experts who don’t know what they are talking about.

What We Know Now

Let’s summarize: According to current evidence, delivery plays a larger role in the formation of stress urinary incontinence and pelvic organ prolapse than does pregnancy (But, baking the baby still matters because urinary incontinence during pregnancy is a large predictor of whether this will continue afterwards). As women age, other factors come into play.

I don’t want to oversimplify the variables, but as a blanket statement, we can say the stroller fitness instructor was wrong. How you give birth absolutely matters when assessing your pelvic floor.

Fine, but who cares? Why bother squashing a myth that doesn’t change much about the way women take care of themselves? I did kegels after my vaginal births and my c-section, so in one sense, the fitness instructor was giving fine advice. Why did I sit down and write this post? Well, ummm, because she was wrong, and confident falsehoods just plain annoy me.

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