Refinement in our ability to identify women most at risk for pelvic floor dysfunction following birth is needed

Determining the causes of pelvic floor dysfunction challenges investigators, as symptoms often appear many years after exposure. Although mode of delivery is thought to contribute to pelvic floor dysfunction, pelvic floor outcomes in the short term reveal few differences between women who deliver by caesarean and women who deliver by normal vaginal birth (Rogers et al. BJOG 2013;121:1145–54). Differences are more likely to be seen when women are exposed to interventions known to increase the risk of pelvic floor dysfunction, including operative vaginal delivery (Handa et al. Obstet Gynecol 2011;118:777–84). Volloyhaug et al. present a survey of women 15–23 years after their first delivery, and investigate the impact of mode of delivery on prolapse, and urinary and anal incontinence symptoms. The authors conclude that caesarean delivery is protective for prolapse and urinary incontinence when compared with normal vaginal delivery, and that operative vaginal delivery increased the risk of prolapse and faecal incontinence compared with vaginal delivery. The findings are not novel but these data from a very large cohort of women with long-term follow-up further substantiate that the largest impact on pelvic floor function is found in women who undergo operative vaginal delivery. Of course, all studies are limited by how exposures and outcomes are measured: in this survey the authors use the PFDI–20 as a screening tool for pelvic floor dysfunction. Whereas individual questions in the PFDI–20 have been used to screen for pro-lapse (Nygaard et al. JAMA 2008;300:1311–6), it is likely that only women with advanced prolapse are identified with a single question. In addition, screening for faecal incontinence is challenging as the terminology used by patients for this embarrassing disorder may vary significantly from the terminology used by healthcare providers (Brown et al. Int J Clin Pract 2012;66:1101–8). Finally, we are not told in this study if women had clinically significant symptoms, just that the symptoms were present. What do we do with this information as we care for women in labour or counsel our patients regarding the benefits and risks of various modes of delivery? In the current study, regardless of delivery mode, approximately half of the women did not report any pelvic floor dysfunction; importantly, caesarean delivery was not completely protective, with prolapse (5%), urinary (39%), and faecal incontinence (9%) reported at significant rates. In addition, this, like prior studies, does not address the economic, fetal, and maternal burden of caesarean delivery, particularly repeat caesarean delivery. Our challenge lies in refining our ability to identify women at highest risk for severe pelvic floor dysfunction following birth, and the birth interventions that we can change to minimise pelvic floor dysfunction for this small cohort RR is the Data Safety Monitoring Chair for the TRANSFORM trial sponsored by American Medical Systems, and receives royalties from Uptodate and McGraw Hill for educational writing.