researching women who birthed 20 or more years ago, whenmedical practices such as forced pushing, episiotomies, and theuse of forceps were common. All such practices have beenshown to significantly increase the risks for damage to the pelvicfloor muscles. To date, there are almost no studies of vaginalbirths done without these practices, making the existing datavery limited in its usefulness. Again, it's a mixed-fruit basket.

And here's a twist:There have been well-documented studiesthat show that a C-section doesn't protect women from thesecomplications. In comparisons of women over age 50 who hadcesareans (or had no children at all) to women who had vaginalbirths, the rates of incontinence problems were the same.

WHAT WE DO KNOWIt's simplistic and misleading to just list the risks of a C-sectioncompared with a vaginal birth, because the risks describedbelow-although well documented-generally derive from studiesof all types of cesareans and almost never from first-time, electivecesareans.What we can do is divide the risks into two categories:

1. Risks that are likely to be present regardless of the reasonthe cesarean was done. These risks are applicable, even in .an elective cesarean.

Risks that exist for all cesareans, including elective:• Longer hospitalization than for vaginal births

• More pain than with vaginal birth• Injury to the mother from surgery, such as accidental cuts

to the bladder or the uterus• Injury to the baby from the surgery, such as accidental cuts

to the baby's head• Higher risk of the baby developing asthma• Unexplained stillbirth in subsequent pregnancies• Catastrophic complications such as an ectopic pregnancy

(tubal pregnancy) and uterine rupture in the next pregnancy• Placental problems that can threaten both the mother's life

and the baby's life in the next pregnancy• Problems with getting pregnant again and possibly an

increased risk of miscarriage

2. Risks that can be related to, or made worse by, the medicalreasons for which the cesareans were performed. Anelective cesarean done without medical reasons might havedecreased risks for these factors, but the risks remain to anunknown degree.

Known risks of medically· indicated cesareans:• Maternal death• Excessive bleeding or hemorrhage• The need for an emergency hysterectomy (surgical removal

of the uterus)• Infection after birth

IREDUCING RISKS IN VAGINAL BIRTHSCertain labor-management and birthing practices have been proven to increase the risk of damage to a woman'spelvic-floor muscles, which in turn could increase her ri~k of incontinence later in life--although that correlationhas not been conclusively proven by current studies. ,

LABOR-MANAGEMENT PRACTICESPUSIDNG: Early pushing, before the baby hasdescended to the pelvic floor and the woman hasa strong urge to push, can increase stress on the pelvic-floor muscles and is associated with potential damageto the bladder connective tissue.

<<PURPLE PUSHING": So-called purple pushing-where the mother is told to hold her breath and pushto the count of 10, three times with each contraction-can lead to the woman being too tired to continuepushing. This increases the need for mechanicalassistance, such as forceps or a vacuum extractor, bothof which are associated with damage. to the pelvic floor.

WRAT YOU CAN DO: The tiD1.llgand merhod

of pushing in the second stage of labor are criticalcomponents to preserving the strength of a woman'spelvic-floor muscles. Don't push until you feel a strongurge to do so. In the case of an epidural, wait untilthe baby's head is very low (called laboring down).This will decrease the time needed for pushing, reducestress on the pelvic floor, and increase effectiveness.

BIRTHING PRACTICESEPISIOTOMY: Cutting the perineum has been proven to createshort-term and long-term damage to the woman's pelvic supportstructure. Episiotomies often lead to "extension" tears that occur afterthe initial cut is made as the baby is born. These tears often lead to moreserious injury.WHAT YOU CAN DO: Discuss your strong preference for noepisiotomy with yourhealthcare provider. It is usually necessaryto do one only in an emergency.

FORCEPS AND VACUUM EXTRACTORS: The use of forcepsfor vaginal birth significantly increases the risk for damage to thepelvic-floor muscles. The use of forceps and vacuum extractors areassociated with the use of episiotomies, which also increases the riskof pelvic-floor injury.WRAT YOU CAN DO: The best w""y to avoid the use of forceps and

vacuum extractors is to work with care providers who rarely use them.

BIRTlllNG POSITIONS: Supine positions, where the mother lieson her back, put more stress on the pelvic-floor structure than otherpositions and can increase the potential for damage from the birth.WHAT YOU CAN DO: Try semi-sitting, squatting, side-lying, usinga birth stool, hands and knees, or even standing while birthing.

"""Problems v.~ blood dots such as stroke or pulmonaryembolism, \ 'ill .n can be life-rhreat~ngHospital re-admission for problems

" Respiratory problems for the baby-.Premature babies

When thinking about an elective cesarean, some women considerer factors, such as convenience, pain avoidance, and future

.~a1 satisfaction. But again, the answers are not black and white.Convenierice and satisfaction: Having a baby in any

5Isbion is an interruption in a woman's life. Being able to choosetiming of your birth is likely to prove to be a small benefit

m the larger scheme of things. Ultimately it is a trade-off Arerisks of elective abdominal surgery versus a spontaneous

mre,.mediated event worth the convenience factor?In the Maternity Center Association landmark srudy of

elective cesareans, mothers were surveyed regarding maternal$ltisfaction with their birthing experiences. Women who had

dergone cesareans were less satisfied (both at the time of birthand later) than mothers who'd had vaginal births.

Pain avoidance: Whether one has labor pain or post-operative pain, the fact remains that childbirth for mostwill always involve some pain, even with the use of narcoticsand anesthesia.

The Maternity Center Association survey found that womenwith cesareans rate themselves as having more pain overall thando mothers with vaginal birth. The pain of labor is limited.The pain of abdominal surgery continues for weeks afterwards.

Bonding and breastfeeding: Cesareans result in delayedcontact with the baby in the critical first hours after birth,postponing mother-child bonding. They also can makebreastfeeding more difficult to establish and more challenging.

Sexual satisfaction: Some women worry about the impactof vaginal birth on their sex life.While birth certainly impactsintimacy on a temporary basis, no evidence exists to suggest that

it is the cause of long-term problems, nor that women who havecesareans face any fewer challenges.

Long-term impact: While not all cesareans are avoidable,it is important to remember that having one cesarean not onlyaffects you and your baby in tins pregnancy, but can impact yourability to both get and stay pregna.'lt the next time. Havinga C-section can also affect the ne:lim of your future children andyour own health during your TIe:>."! pregnancy and birth.

m.

FOR THE BEST AND SAfES BIRTHWhile the times have changec. \:,1:~,:ping has not: The safestbirth is still a vaginal birth:G.7:.i _~not include labor and birthpractices known to damage :r'J-::'~~,;::\":ic floor. There is notenough information at tllli =~:0 echically say that an elective

; C-section is as safe or safer :::::= ,;.,. .nal birth. And there is noevidence that birth by abio-::-'-..:i s-o!..?"- protects women

against incontinence issues :-u ::a:<:-::i."lt.Take the time to discuss ~::z ~5i(\'ns> concerns, and

preferences with your he2lt::::'~E:;. :l!.:"T.f\sk for what you need.It is, after all, your body. yo::::- ::~: y"UU, birth.

. he,ILlJrT

dr.