By J. M. Anderson, M.D. published in Style Magazine May 2004

As an obstetrician-gynecologist in the new millennium, I am encountering a subset of reproductive aged women in their thirties who are inquiring about the best mode of delivery for their unborn children.  Women who have yet to start their families are becoming aware of the fact that, to some degree, vaginal delivery (especially prolonged labors and multiple deliveries) does increase the chance of having pelvic floor dysfunction (i.e. incontinence) later in life that might require surgical correction.  Historically, cesarean delivery has been the back up or alternate route of delivery and the vaginal route the standard.  The reason is that a cesarean delivery conferred higher rates of morbidity and mortality.  However, with advances in surgical techniques and preventative measures, complications from c-sections have dropped significantly.  The question facing Ob-Gyns today is should women be offered  elective cesarean sections in an attempt to preserve the integrity of their pelvic floor? 

As in many areas of medicine, setting the standards for who is or is not a candidate for a particular procedure can be very difficult to define, and is to some extent subjective.  Though many physicians would advocate that patient autonomy after informed consent to be of highest value, one must also consider the virtue of non-maleficence or "do no harm."  Having one c-section undoubtedly places any subsequent pregnancy into a higher risk category because of the risks of uterine rupture or abnormal placental location- both of which can cause catastrophic hemorrhage (death to both mother and baby).  Though the risks of these complications are small after only one c-section, the more cesareans a woman undergoes, the higher the risks escalate.  It stands to reason that if a woman plans to have a large family, she would not be the ideal candidate for elective cesarean deliveries.  But what about women who want one or two children? One could argue that it would be easier to recover from a c-section at the age of thirty than it would be to have extensive pelvic reconstruction in the 5th or 6th decade of life which may have only limited success.   

 Retrospective studies of women with urinary incontinence and other various pelvic floor disruptions (rectoceles, cystoceles, uterine prolapse, fecal incontinence) do show a linear relationship between the number of labors/vaginal deliveries to these conditions.  Current expert opinion holds that though these are not the sole reasons for future incontinence, they are contributory.  So is the assumption that undergoing cesarean deliveries before the onset of labor will prevent future incontinence?  Not exactly, but possibly…to some degree.  

Although this short editorial only scratches the surface of the issue, let me assure you there is nothing black and white about the appropriateness of elective cesarean deliveries when a trial of labor is still an option.  The best advise for women is to get informed on all known risks and benefits by talking to their obstetrician early in their pregnancy so that both doctor and patient can arrive at an agreed upon delivery plan (saying nothing of the fact that insurance companies are unlikely to approve an elective primary c-section over a trial of labor because of cost concerns).  I personally feel that there is a place in obstetrics for elective cesarean deliveries, but only if the patient is a candidate and that is determined on a case by case basis.