Clinical Question: Are nulliparous women who have a cesarean delivery less likely to develop pelvic organ prolapse than women who deliver vaginally?

Setting: Outpatient (specialty)

Study Design: Cohort (prospective)

Synopsis: Investigators evaluated a cohort of 101 nulliparous women who had uncomplicated singleton pregnancies for pelvic organ prolapse according to the International Continence Society staging system. They compared the amount of prolapse at 36 weeks of gestation to that at six weeks postpartum. Women were grouped by type of delivery for comparisons. Staging was done by measuring the distances (cm) from the cervix, vaginal walls, and posterior fornix to the hymen while the woman performed a maximal Valsalva's maneuver. Stage 0 is normal, stage I indicates defect in support with all measurements at least 1 cm above the hymen, and stage II is one or more measurements between 1 cm above to 1 cm below the hymen. Seven women did not return for their postpartum visit and were excluded from analysis.

At the 36-week visit, 43 women (46 percent) had a prolapse with 24 women (26 percent) at stage II. At the postpartum visit, 78 women (83 percent) had prolapse, 50 (52 percent) of whom were at stage II. Thirty-five women (37 percent) developed new prolapse,18 (19 percent) from stage 0 to stage II. In 14 women (15 percent), the prolapse progressed from stage I to II. Rates of new prolapse, worsening prolapse, and a two-stage increase were similar between women with spontaneous vaginal deliveries (n = 41) and those who underwent cesarean delivery in the first stage of labor (n = 28). Based on power analysis, the authors could conclude no difference between the groups.

Groups of women with cesarean delivery in the second stage of labor (n = 4) or during the latent phase of labor (n = 2), elective cesarean delivery (n = 3), or operative vaginal delivery (n = 11) were too small to make statistically valid comparisons, but all groups showed increased rates of prolapse postpartum. Black women were as likely as white women to develop prolapse. The quality of this study was compromised somewhat because there was no mention of blinding to mode of delivery among physicians who made the postpartum assessments of prolapse.

Bottom Line: This study shows that cesarean delivery during active labor does not protect women from developing pelvic organ prolapse related to childbirth. (Level of Evidence: 1b)