Evidence Library · Long-term questions

The pelvic floor: what cesarean does and does not prevent

The population data and the randomized data point in different directions.

This is regularly oversimplified in both directions, so here is what the evidence actually shows.

Population data favor cesarean. A meta-analysis of 15 studies at one year or more found stress urinary incontinence more common after vaginal birth, with an absolute risk difference of 8.2 percentage points. A Swedish register study found the risk of prolapse surgery was 0.09 per 1,000 women after cesarean-only deliveries compared with 2.11 per 1,000 after vaginal birth, a 23-fold difference, and risk rose with each vaginal birth but stayed flat with cesarean.

Randomized data do not. In the two-year follow-up of the Term Breech Trial, with 917 women who had been randomly assigned, there were no significant differences between planned cesarean and planned vaginal birth in urinary incontinence, fecal incontinence, sexual problems, or depression. Constipation was actually more common in the planned cesarean group.

Reconciling the twoOne cesarean instead of one vaginal birth appears to buy very little pelvic floor protection. The large registry differences accumulate across several vaginal births and across decades. The protective effect is also larger in younger women and shrinks with age. Choosing a cesarean specifically to protect the pelvic floor is not well supported by the randomized evidence.

Where this comes from:

327. Smith GC, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet. 2003;362(9398):1779-1784.

329. Tähtinen RM, Cartwright R, Tsui JF, Aaltonen RL, Aoki Y, Cárdenas JL, et al. Long-term impact of mode of delivery on stress urinary incontinence and urgency urinary incontinence: a systematic review and meta-analysis. Eur Urol. 2016;70(1):148-158.

330. Larsudd-Kåverud J, Gyhagen J, Åkervall S, Molin M, Milsom I, Wagg A, et al. The influence of pregnancy, parity, and mode of delivery on urinary incontinence and prolapse surgery: a national register study. Am J Obstet Gynecol. 2023;228(1):61.e1-61.e13.

331. Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term. Am J Obstet Gynecol. 2004;191(3):917-927.

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