Sept. 2, 2004 -- Women who have emergency C-sections during difficult deliveries report fewer urinary and short-term sexual problems than women who have forceps- or vacuum-assisted vaginal delivery.
But emergency C-sections are much more difficult than planned C-sections, and they carry risks of their own, a British study shows. Moreover, women who had instrument-assisted deliveries say they'd do it again rather than have C-sections.
Researchers Rachel E. Liebling, MD, of Royal United Hospital in Bath, England, and colleagues therefore argue that doctors should continue to offer women a choice between emergency C-sections and instrument-assisted delivery.
"We would support the continued practice of instrumental vaginal delivery," they write in the July issue of the American Journal of Obstetrics and Gynecology.
Difficult Birth, Difficult Choice
A normal vaginal delivery is the goal for most pregnant women. But labor sometimes comes to a halt too soon. At this point, the mother-to-be and her doctor have two choices: emergency C-section to deliver the baby, or assisted delivery using a forceps or a vacuum device attached to the head of the fetus.
In professional hands, all of these methods are safe and effective. All are equally likely to result in a healthy baby. But all result in some injury to the woman. Which is least harmful to the mother? Liebling and colleagues followed up on 393 women who had gone through prolonged labor. Doctors delivered 209 babies via C-section and 184 babies via instruments.
Six weeks later and a year later, Liebling's team asked the women how they were doing. After six weeks, the women who underwent C-sections were nearly eight times less likely to have urinary incontinence. After a year, this symptom was still three times less frequent in the women who underwent emergency C-sections.
Nearly 60% of the women reported at least one symptom of bowel dysfunction, but there was no significant difference between groups. However, women who underwent instrumental delivery were more likely to have constipation after one year.
Six weeks after delivery, pain during sex was about three times more likely in the instrument-assisted group. However, over time this became less frequent for these women and more frequent for the women who underwent C-sections. And emergency C-sections were twice as likely to result in sexual dysfunction as planned, non-emergency C-sections.
This doesn't surprise Audra Timmins, MD, assistant professor of obstetrics and gynecology at Baylor College of Medicine in Houston.
"In someone who has gone all the way through labor and has pushed and pushed, a C-section doesn't save you anything," Timmins tells WebMD. "All the damage is done. There is no benefit to a mom. And the recovery is longer after a C-section."
That's because an emergency C-section is very different from a planned C-section, says Julian N. Robinson, MD, attending physician at Brigham and Women's Hospital in Boston and director of maternal and fetal medicine at Newton-Wellesley Hospital.
"If you look at C-section at the onset of labor, it is straightforward and simple. But at full dilation that is not the case," Robinson tells WebMD. "For the obstetrician, it is a very difficult scenario. C-section is not an easy option for a woman at full dilation. You are between a rock and a hard place. Forceps and vacuum delivery may be challenging, but C-section may be challenging as well. These are the C-sections that women have the most complications from."
Making the Choice
At her institution, Timmins says, the policy is for pregnant women and their doctors to discuss what might happen during labor long before the event.
"Basically, if I am comfortable that mother and fetus met all criteria for safe forceps delivery, I will offer them a trial," Timmins says. "If they have strong opinions, and say they don't want them used, we don't use them. We don't force them on anybody. But most of the time women and their partners understand that, in well-trained hands, a forceps or vacuum delivery is just as safe as a C-section."