Abstract
Background
Cesarean delivery (CD), is increasingly recommended as a mode of delivery that prevents the anal incontinence (AI) that arises in some women after vaginal delivery (VD). The assessment of the efficacy of CD in this regard was the subject of this systematic review.
Methods
Searches were conducted in Medline, EMBASE and the Cochrane Library. Both randomized (RCTs) and non-randomized trials (NRTs) comparing the risk of sustained fecal and/or flatus incontinence after VD or CD were sought from 1966 to 1 January, 2019. Studies were eligible if they assessed AI more than 6 months after birth, and had statistical adjustment for at least one of the three major confounders for AI: age, maternal weight or parity. In addition, each study was required to contain more than 250 participants, more than 50 CDs and more than 25 cases of AI. Data after screening and selection were abstracted and entered into Revman for meta-analysis. Analyses were done for combined fecal and flatus incontinence (comAI), fecal incontinence (FI), gas incontinence (GI), CD before or during labor, time trend of incontinence after delivery, assessment of both statistical and clinical heterogeneity, parity and late incident AI.
Results
Out of the 2526 titles and abstracts found, 24 eligible studies were analyzed, 23 NRTs and one RCT. These included women with 29,597 VDs and women with 6821 CDs. Among the primary outcomes, VD was found not to be a significant predictor of postpartum comAI compared to CD in 6 studies, incorporating 18,951 deliveries (OR = 0.74; 0.54–1.02). VD was also not a significant predictor of FI in 14 studies, incorporating 29,367 deliveries, (OR = 0.89; 0.76–1.05). VD was not a significant predictor of GI in six studies, incorporating 6724 deliveries (OR = 0.96; 0.79–1.18). The strength of the grading of recommendations, assessment, development and evaluations (GRADE) evidence for each of these was low for comAI and moderate for FI and GI (upgrade for lack of expected effect). Time trend FI showed incontinence at 3 months often resolved at 1 year. Other secondary analyses assessing parity, delayed incidence of FI, clinical and statistical heterogeneity, spontaneous VD only, late risk of incidence of AI, and CD in or prior to labor all had similar results as in the primary outcomes.
Conclusions
There are three components of pelvic floor dysfunction that are thought to be caused by VD and hopefully prevented by CD: AI, urinary incontinence and pelvic floor prolapse. Of these, AI was not found to be reliably prevented by CD in this review.
Similar content being viewed by others
Change history
16 August 2020
The original article can be found online
References
Oberwalder M, Connor J, Wexner SD (2003) Meta-analysis to determine the incidence of obstetric anal sphincter damage. Br J Surg 90:1333–1337
Nelson RL (2004) Epidemiology of fecal incontinence. Gastroenterol 126:s3–s7
Nelson RL, Furner S, Jesudason V (1998) Fecal incontinence in Wisconsin nursing homes: prevalence and Associations. Dis Colon Rectum 41:1226–1229
Higgins JPT, Green S (editors) (2008) Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0 www.cochrane-handbook.org The Cochrane Collaboration
Kepenekci I, Keskinkilic B, Akinsu F, Cakir P, Elhan AH, Erkek AB, Kuzu MA (2011) Prevalence of pelvic floor disorders in the female population and the impact of age, mode of delivery and parity. Dis Colon Rectum 54:85–94
Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A (2016) Mode of delivery after obstetric anal sphincter injury and the risk of long-term anal incontinence. Am J Obstet Gynecol 214(6):733
Schünemann H, Brożek J, Guyatt G, Oxman A (eds) (2013) The GRADE Working Group. GRADE Handbook for Grading Quality of Evidence and Strength of Recommendations. Available from https://gdt.guidelinedevelopment.org/app/handbook/handbook.html. Updated October 2013
Blomquist JL, Muñoz A, Carroll M, Handa VL (2018) Association of delivery mode with pelvic floor disorders after childbirth. JAMA 320(23):2438–2447
Dolan LM, Hilton P (2010) Obstetric risk factors and pelvic floor dysfunction 20 years after first delivery. Int Urogynecol J 21(5):535–544
Fritel X, Schaal JP, Fauconnier A, Bertrand V et al (2008) Pelvic floor disorders 4 years after first delivery: a comparative study of restrictive versus systematic episiotomy. BJOG 115(2):247–252
Gyhagen M, Bullarbo M, Nielsen TF, Milsom I (2018) Faecal incontinence 20 years after one birth: a comparison between vaginal delivery and caesarean section. Int Urogynecol J 25(10):1411–1418
Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Munoz A (2011) Pelvic floor disorders 5–10 years after vaginal or cesarean childbirth. Obstet Gynecol 118(4):777–784
Lucasz ES, Lawrence JM, Contreras R, Nager CW, Luber KM (2006) Parity, mode of delivery and pelvic floor disorders. Obstet Gynecol 107:1253–1260
Schei B, Johannessen HH, Rydning A, Sultan A, Mørkved S (2019) Anal incontinence after vaginal delivery or cesarean section. Acta Obstet Gynecol Scand 98(1):51–60
Abramov Y, Sand PK, Botros SM, Goldberg RP et al (2005) Risk factors for female anal incontinence: new insight through the Evanston-Northwestern twin sisters study. Obstet Gynecol 106:726–732
Altman D, Ekstrom A, Frosgren C, Nordenstam J, Zetterstrom J (2007) Symptoms of anal and urinary incontinence following cesarean section or spontaneous vaginal delivery. Am J Obstet Gynecol 197:512.e1–e7
Brown SJ, Gartland D, Donath S, MacArthur C (2012) Fecal incontinence during the first 12 months postpartum: complex causal pathways and implications for clinical practice. Obstet Gynecol 119(2 Pt 1):240–249
Burgio KL, Borello-France D, Richter HE, Fitzgerals MP et al (2007) Risk factors for fecal and urinary incontinence after childbirth: the childbirth and pelvic symptoms study. Am J Gastro 102:1998–2004
Gartland D, MacArthur C, Woolhouse H, McDonald E, Brown SJ (2016) Frequency, severity and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort. BJOG Int J Obstet Gynaecol 123(7):1203–1211
Goldberg RP, Kwon C, Gandhi S, Atkuru LV et al (2003) Prevalence of anal incontinence among mothers of multiples and analysis of risk factors. Am J Obstet Gynecol 189:1627–1631
Hutton EK, Hannah ME, Willan AR, Ross S, Allen AC, Armson BA et al (2018) Urinary stress incontinence and other maternal outcomes two years after Caesarean or vaginal birth for twin pregnancy: a multicentre randomized trial. BJOG 125(13):1682–1690
MacArthur C, Glazener CM, Wilson PD, Herbison GP, Gee H, Lang GD et al (2001) Obstetric practice and faecal incontinence three months after delivery. BJOG 108(7):678–683
MacArthur C, Glazener CMA, Lancashire R, Herbison P et al (2005) Faecal incontinence and mode of first and subsequent delivery: a six-year longitudinal study. BJOG 112:1075–1082
MacArthur C, Glazener C, Lancashire R, Herbison P, Wilsond D (2011) Exclusive caesarean section delivery and subsequent urinary and faecal incontinence: a 12-year longitudinal study. BJOG 118(8):1001–1007
MacLennan AH, Taylor AW, Wilson DH, Wilson D (2000) The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. J Obstet Gynecol 107:1460–1470
McKinnie V, Swift S, Wang W, Woodman P, O’Boyle A, Kahn M, Valley M, Bland D, Shaffer J (2005) The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence. Am J Obstet Gynecol 103(2):512–518
Melville JL, Fan M-Y, Newton K, Fenner D (2005) Fecal incontinence in US women: a population-based study. Obstet Gynecol 193:2071–2076
Rommen K, Schei B, Rydning A, Daltveit AK, Sultan A, Morkved S (2011) Prevalence of fecal incontinence after vaginal deliveries versus caesarean sections. Female Pelvic Med Reconstr Surg 17(5):767–768
Varma MG, Brown JS, Creasman JM, Thom DH, van den Eeden SK, Beattie MS, Subak LL (2006) Fecal incontinence in females older than 40 years: who is at risk? Dis Colon Rectum 49(6):841–851
Volloyhaug I, Morkved S, Salvesen O, Salvesen K (2015) Pelvic organ prolapse and incontinence 15–23 years after first delivery: a cross-sectional study. BJOG 122(7):964–971
Woolhouse H, Perlen S, Gartland D, Brown SJ (2012) Physical health and recovery in the first 18 months postpartum: does cesarean section reduce long-term morbidity? Birth (Berkeley, Calif.) 39(3):221–229
Hannah ME, Hannah WJ, Hodnett ED et al (2002) Outcomes at 3 months after planned Cesarean vs. planned vaginal delivery for breech presentation at term. JAMA 287:1822–1831
Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M, Gafni A et al (2004) Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized term breech trial. Am J Obstet Gynecol 191:917–927
Johannessen HH, Wibe A, Stordahl A, Sandvik L, Backe B, Morkved S (2019) Prevalence and predictors of anal incontinence during pregnancy and 1 year after delivery: a prospective cohort study. Neurol Urodyn 38(1):310–319
Goffeng AR, Andersch B, Andersson M, Berndtsson I, Hulten L, Oreslan T (1998) Objective methods cannot predict anal incontinence after primary repair of extensive anal tears. Acta Obstet Gynecol Scand 77:439–443
Guttierz AB, Madoff RD, Lowry AC, Parker SC, Buie WD, Baxter NN (2004) Long term results of anterior sphincteroplasty. Dis Colon Rectum 47:727–732
Halverson AN, Hull TL (2002) Long-term outcome of overlapping anal sphincter repair. Dis Colon Rectum 45:345–348
Karoui S, Leroi AM, Koning E, Menar JF, Michot F, Dens P (2000) Results of sphincteroplasty in 86 patients with anal incontinence. Dis Colon Rectum 43:813–820
Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm MA (2000) Long-term results of overlapping anterior anal sphincter repair for obstetrical trauma. Lancet 355:260–265
Pinta T, Kyaanpaa ML, Salmi T, Jaarvinen HJ, Luukkonen P (2003) Delayed sphincter repair for obstetric ruptures: analysis of failure. Colorectal Dis 5:73–78
Rothbart J, Bemelman WA, Meijerink WJ (2000) Long term results of anterior anal sphincter repair for rectal incontinence due to obstetric injury. Dig Surg 17:390–394
Vaizey CJ, Norton C, Thornton MJ, Nicholls RJ, Kamm MA (2004) Long term results of repeat anterior anal sphincter repair. Dis Colon Rectum 47:858–863
Amu O, Rajendran S, Bolaji II (1998) Should doctors perform an elective cesarean section on request? maternal choice alone should not determine method of delivery. BMJ 317:463–465
Abramatowitz I, Sobhani I, Ganansia R (2000) Are sphincter defects the cause of anal incontinence after vaginal delivery? results of a prospective survey. Dis Colon Rectum 43:590–596
Farrell SA (2002) Cesarean section versus forceps-assisted vaginal birth: it’s time to include pelvic injury in the risk benefit equation. Can Med Assoc J 155:117–118
Faridi FA, Willis S, Schelzig P, Siggelkow W, Schumpelick V, Rath W (2002) Anal sphincter injury during vaginal delivery—an argument for cesarean section on request? Perinat. Med 30:379–387
Guise JM, McDonough MS, Osterwell P, Nygren P, Chan KS, Helfand M (2004) Systematic review of the incidence and consequences of uterine rupture in women with previous cesarean section. BMJ 329:1–7
Idama TO, Lindow SW (1999) Safest option is still to aim for vaginal delivery. BMJ 318:121
Zetterstrom J, Lopez A, Anzen B, Dolk A, Norman M, Mellgren A (1999) Anal incontinence after vaginal delivery: a prospective study in primiparous women. Obstete Gynecol 106:324–330
Nygaard IE, Cruickshank FA (2003) Should all women be offered elective cesarean section. Obstet Gynecol 102:217–219
Paterson-Brown S (1998) Should doctors perform an elective caesarean section on request? yes, as long as the woman is fully informed. BMJ 317:462–463
Lockwood CJ (2004) Cesarean delivery: is it time to embrace elective procedures? Contemp Obstet Gynecol 12:8–10
Minkoff H, Chervenak FA (2003) Elective primary cesarean delivery. N Eng J Med 348:946–950
NIH Consensus Conference. Cesarean Delivery on Maternal Request (2006) NIH consensus and state of the science statements; http://consensus.nih.gov/2006/CesareanStatement_Final053106.pdf 23(1):1–29
Declercq E, Menacker F, MacDorman M (2005) Rise on “no indicated risk” primary caesareans in the United States, 1991–2001: cross sectional analysis. BMJ 330:71–73
van Roosmalen J (1999) Unnecessary caesarean sections should be avoided. BMJ 318:121
Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR (2016) The increasing trend in caesarean section rates: global, regional and national estimates: 1990–2014. PLoS One 11(2):e0148343
Hsu KH, Liao PJ, Hwang CJ (2008) Factors affecting Taiwanese women’s choice of Cesarean section. Soc Sci Med 66(1):201–209
Behague DP, Victoria CG, Barros FC (2002) Consumer demand for caesarean sections in Brazil; informed decision making, patient choice or social inequality? a population based birth cohort study linking ethnographic and epidemiological methods. BMJ 321:1–6
Potter JE, Berquo E, Perpetuo IHO, Leal OF, Hopkins K, Souza MR, de Carvalho Formiga MC (2001) Unwanted caesarean sections among public and private patients in Brazil: prospective study. BMJ 323:1155–1158
Murray S (2000) Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study. BMJ 321:1501–1505
Keag OE, Norman JE, Stock SJ (2018) Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis. PLoS Med 15(1):e1002494
Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, Gibbons D, Kelly NM, Kennedy HP, Kidanto H, Taylor P, Temmerman M (2018) Short-term and long-term effects of caesarean section on the health of women and children. Lancet 392(10155):1349–1357
The Childbirth Connection. The cost of Having a Baby. http://transform.childbirthconnection.org/reports/cost/
Nelson RL, Furner SE, Westercamp M, Farquhar C (2010) Cesarean delivery for the prevention of anal incontinence. Cochrane Database Syst Rev 2:CD006756
Pretlove SJ, Thompson PJ, Toozs-Hobson PM, Radley S, Khan KS (2008) Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review. BJOG 115(4):421–434
Rørtveit G, Hannestad YS (2014) Association between mode of delivery and pelvic floor dysfunction. Tidsskr Nor Laegeforen 134(19):1848–1852
Tähtinen RM, Cartwright R, Tsui JF, Aaltonen RL, Aoki Y, Cárdenas JL, El Dib R, Joronen KM, Al Juaid S, Kalantan S, Kochana M, Kopec M, Lopes LC, Mirza E, Oksjoki SM, Pesonen JS, Valpas A, Wang L, Zhang Y, Heels-Ansdell D, Guyatt GH, Tikkinen KAO (2016) Long-term impact of mode of delivery on stress urinary incontinence and urgency urinary incontinence: a systematic review and meta-analysis. Eur Urol 70(1):148–158
Shorten A (2007) Maternal and neonatal effects of caesarean section; more accurate estimates of benefits and harms are needed to support informed childbirth choices. BMJ 335:1003–1004
Tilbrook H (2009) Patients’ preferences within randomized trial: systematic review and patient level meta-analysis. BMJ 338:85–88
Turner CE, Young JM, Solomon MJ, Ludlow Bennes C, Phipps H (2008) Willingness of pregnant women and clinicians to participate in a hypothetical randomized controlled trial comparing vaginal delivery and elective caesarean section. Aust New Zeal J Obstet Gynecol 48:542–546
Lavender T, Kingdon C, Hart A, Gyte G, Gabbay M, Neilson JP (2005) Could a randomized trial answer the controversy relating to elective caesarean section? National survey of consultant obstetricians and heads of midwifery. BMJ 331:490–491
Kotaska A (2004) Inappropriate us of randomized trials to evaluate complex phenomena: a case study. BMJ 329:1039–1042
Alfirevic Z, Milan SJ, Livio S (2013) Caesarean section versus vaginal delivery for preterm birth in singletons. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD000078.pub3
Whitehead WE, Borrud L, Goode PS, Meikle S, Mueller ER, Tuteja A, Weidner A, Weinstein M, Ye W (2009) Pelvic floor disorders network. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology 137(2):512–517
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
This article does not contain any studies with human participants or animals performed by any of the authors.
Informed consent
For this type of study, formal consent is not required.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Appendix
Appendix
Search strategy for NEL103: cesarean delivery for the prevention of anal incontinence
Medline (Ovid) 1/1/2019
Search history
-
1.
exp Cesarean Section/
-
2.
exp Delivery, obstetric/
-
3.
[((cesarean or caesarean) adj section) or delivery or c? section or c-section].m_titl.
-
4.
1 or 2 or 3
-
5.
exp Fecal incontinence/
-
6.
exp Urinary incontinence/
-
7.
[(anal or fecal or urin*) adj incontinence].m_titl.
-
8.
5 or 6 or 7
-
9.
4 and 8
-
10.
randomized controlled trial.pt.
-
11.
controlled clinical trial.pt.
-
12.
randomized.ab.
-
13.
placebo.ab.
-
14.
clinical trial.sh.
-
15.
randomly.ab.
-
16.
trial.ti.
-
17.
10 or 11 or 12 or 13 or 14 or 15 or 16
-
18.
humans.sh.
-
19.
17 and 18
-
20.
exp epidemiology/or exp epidemiologic studies/or exp case–control studies/or exp cohort studies/or exp longitudinal studies/or exp retrospective studies/or exp cross-sectional studies/or intervention studies/
-
21.
(epidemiolog* or incidence or prevalence or case–control or cohort* longitudinal or retrospectiv* cross-sectional or intervention).mp.
-
22.
20 or 21
-
23.
19 or 22
-
24.
9 and 23
Embase (Ovid) 1/1/2019
Search history
-
1.
exp cesarean section/
-
2.
exp delivery/
-
3.
(((cesarean or caesarean) adj section) or delivery or c? section or c-section).m_titl.
-
4.
1 or 2 or 3
-
5.
exp feces incontinence/
-
6.
exp urine incontinence/
-
7.
((anal or fecal or urin*) adj incontinence).m_titl.
-
8.
5 or 6 or 7
-
9.
4 and 8
-
10.
randomized controlled trial/
-
11.
randomization/
-
12.
controlled study/
-
13.
multicenter study/
-
14.
phase 3 clinical trial/
-
15.
phase 4 clinical trial/
-
16.
double blind procedure/
-
17.
single blind procedure/
-
18.
((singl* or doubl* or trebl* or tripl*) adj (blind* or mask*)).ti,ab.
-
19.
(random* or cross* over* or factorial* or placebo* or volunteer*).ti,ab
-
20.
15 or 12 or 16 or 18 or 11 or 17 or 13 or 10 or 19 or 14
-
21.
“human*”.ti,ab.
-
22.
(animal* or nonhuman*).ti,ab.
-
23.
22 and 21
-
24.
22 not 23
-
25.
20 not 24
-
26.
exp epidemiology/
-
27.
(epidemiolog* or incidence or prevalence or case–control or cohort* longitudinal or retrospectiv* cross-sectional or intervention).mp.
-
28.
26 or 27
-
29.
25 or 28
-
30.
9 and 29
Cochrane library 1.1.19
#1 MeSH descriptor Cesarean Section explode all trees #2 MeSH descriptor Delivery, Obstetric explode all trees
#3 (((cesarean or caecarean) near section) or delivery or c? section or c-section):ti #4 (#1 OR #2 OR #3)
#5 MeSH descriptor Fecal Incontinence explode all trees #6 MeSH descriptor Urinary Incontinence explode all trees #7 ((anal or fecal or urin*) near incontinence):ti
#8 (#5 OR #6 OR #7)
#9 (#4 AND #8)
Rights and permissions
About this article
Cite this article
Nelson, R.L., Go, C., Darwish, R. et al. Cesarean delivery to prevent anal incontinence: a systematic review and meta-analysis. Tech Coloproctol 23, 809–820 (2019). https://doi.org/10.1007/s10151-019-02029-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10151-019-02029-3