Cesarean and vaginal birth: cohort study of the impact on pelvic floor disorders

描述(由申请人提供)：鉴于每年有350,000例外科手术用于治疗尿失禁或其他盆底疾病(PFD)，因此需要有效的预防策略。产科医生将预防大小便失禁作为选择性剖腹产的主要理由。然而，目前尚不清楚选择性剖宫产是否能有效预防产后功能障碍。特别是，几乎没有关于分娩方式对盆腔器官脱垂长期发生率的影响的信息。2006年NICHD关于产妇要求剖腹产的会议强调了这一点和其他关于“病人选择”剖腹产的争议。为了调查选择性剖宫产在预防盆腔器官脱垂和其他产后功能障碍方面的有效性，我们提出了一项队列研究，研究对象为1998-2003年间分娩第一个孩子的1000名妇女。非暴露组将是通过非分娩剖腹产(UCD)分娩的妇女。我们将招募两个对照暴露人群，按第一胎出生日期(3个月)与UCD组匹配：通过剖宫产分娩的妇女(LCD)和经阴道分娩的妇女(VB)。这三组患者的尿失禁和肛门失禁的累积发生率将使用有效的问卷进行评估。为了对盆腔器官脱垂进行识别和分类，我们将对所有参与者进行标准化的体检。我们的具体目标是：(1)调查未分娩的剖宫产是否与产后或阴道分娩后剖宫产的累积发生率较低有关，(2)调查引产、会阴切开术和手术分娩等分娩干预措施是否对PFDs的累积发生率有显著影响。此外，我们将(3)对登记的参与者进行纵向队列研究，并每年跟踪这三组人，以调查PFDs的长期发病率。我们将具体比较UCD组与LCD和VB对照组中PFDs的发生率。这项研究是新颖的，因为我们将专注于将UCD与其他分娩方式进行比较，因为我们将使用可重复和定量的体检来评估脱垂，因为纵向设计将使我们能够描述随着时间的推移PFDs的发生率和自然历史。通过研究分娩如何影响女性盆底问题的风险，我们将为女性及其医生提供新的、有价值的信息。我们正处于产科的十字路口，剖腹产率创历史新高。我们的发现将与预期分娩的妇女直接相关，从公共卫生的角度来看，将有助于确定有效的预防方案。公共卫生相关性：鉴于美国每年为治疗大小便失禁和盆腔器官脱垂而进行的大型手术超过35万例，预防策略至关重要。我们知道分娩是这些盆底问题的主要风险因素，但这项研究将调查 剖腹产降低了盆底问题的长期风险。通过研究剖腹产是否可以减少大小便失禁和盆腔器官脱垂，我们将提供与女性及其产科医生面临的决定直接相关的信息。从公共卫生的角度来看，这项研究将有助于确定是否可以改进产科护理，以防止妇女在以后的生活中出现健康问题。

DESCRIPTION (provided by applicant): Given that 350,000 surgical procedures are performed each year to treat urinary incontinence or other pelvic floor disorders (PFDs), effective prevention strategies are needed. Obstetricians cite the prevention of incontinence as a primary justification for elective Cesarean delivery. However, it's not known whether elective Cesarean is effective in preventing PFDs. In particular, there is virtually no information about the impact that delivery mode has on the long-term incidence of pelvic organ prolapse. The 2006 NICHD conference on Cesarean Delivery on Maternal Request highlighted this and other controversies about "patient-choice" Cesarean. To investigate the effectiveness of elective Cesarean in preventing pelvic organ prolapse and other PFDs, we propose a cohort study of 1000 women who delivered a first child from 1998- 2003. The unexposed group will be women delivered by unlabored Cesarean delivery (UCD). We will recruit two comparison exposed populations, matched to the UCD group by date of first birth ( 3 months): women delivered by labored Cesarean delivery (LCD), and women delivered by vaginal birth (VB). The cumulative incidence of urinary and anal incontinence will be assessed in these three groups using validated questionnaires. To identify and classify pelvic organ prolapse, we will use a standardized physical examination for all participants. Our specific aims are: (1) to investigate whether unlabored Cesarean delivery is associated with a lower cumulative incidence of PFDs (5-10 years from delivery) than either Cesarean after the onset of labor or vaginal birth, and (2) to investigate whether labor interventions, such as labor induction, episiotomy and operative delivery, have a significant effect on the cumulative incidence of PFDs. In addition, we will (3) develop a longitudinal cohort study of enrolled participants and follow these three groups annually to investigate the long-term incidence of PFDs. We will specifically compare the incidence of PFDs in the UCD group with the incidence in the LCD and VB comparison groups. This study is novel because we will focus on comparing UCD to other modes of delivery, because we will use a reproducible and quantitative physical examination to assess prolapse, and because the longitudinal design will allow us to describe the incidence and natural history of PFDs over time. By studying how childbirth affects a woman's risk of pelvic floor problems, we will provide new, valuable information for women and their doctors. We are at a crossroads in obstetrics, with an all-time high in Cesarean birth. Our findings will have immediate relevance to women anticipating childbirth and, from a public health perspective, will help to identify effect prevention options. PUBLIC HEALTH RELEVANCE: Given that more than 350,000 major surgeries are performed in the US each year for treatment of incontinence and pelvic organ prolapse, prevention strategies are critical. We know that childbirth is a major risk factor for these pelvic floor problems, but this study will investigate whether Cesarean birth reduces the long-term risk of pelvic floor problems. By investigating whether Cesarean reduces incontinence and pelvic organ prolapse, we will provide information with immediate relevance to decisions faced by women and their obstetricians. From a public health perspective, this research will help to establish whether obstetrical care can be modified to prevent women's health problems later in life.