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

描述（由申请人提供）：鉴于每年进行350，000例手术治疗尿失禁或其他骨盆底疾病（PFDs），因此需要有效的预防策略。产科医生引用预防尿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腹产是否能有效预防PFDs。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。为了探讨选择性剖宫产术在预防盆腔器官脱垂和其他PFDs方面的有效性，我们提出了一项队列研究，研究对象为1998- 2003年期间分娩第一个孩子的1000名妇女。未暴露组将是通过非人工剖腹产（UCD）分娩的女性。我们将招募两个对照暴露人群，按首次分娩日期（3个月）与UCD组匹配：剖腹产分娩（LCD）的女性和阴道分娩（VB）的女性。将使用经验证的问卷评估这三组中尿失禁和肛门失禁的累积发生率。为了识别和分类盆腔器官脱垂，我们将对所有参与者进行标准化体格检查。我们的具体目标是：（1）调查非分娩剖宫产是否与分娩开始后剖宫产或阴道分娩相比，其PFDs的累积发生率（分娩后5-10年）较低，（2）调查分娩干预（如引产、会阴切开术和手术分娩）是否对PFDs的累积发生率有显著影响。此外，我们将（3）对入组的受试者开展纵向队列研究，并每年随访这三组受试者，以调查PFDs的长期发生率。我们将专门比较UCD组与LCD和VB对照组的PFDs发生率。这项研究是新颖的，因为我们将重点比较UCD与其他分娩方式，因为我们将使用可重复的定量体格检查来评估脱垂，并且因为纵向设计将使我们能够描述随时间推移的PFDs的发病率和自然史。通过研究分娩如何影响女性骨盆底问题的风险，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，剖腹产率达到历史最高水平。我们的研究结果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：鉴于美国每年有超过35万例大手术用于治疗尿失禁和盆腔器官脱垂，预防策略至关重要。我们知道，分娩是这些骨盆底问题的主要危险因素，但这项研究将调查是否 剖腹产降低了骨盆底问题的长期风险。通过调查剖腹产是否减少尿失禁和盆腔器官脱垂，我们将提供与妇女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修改产科护理，以防止妇女在以后的生活中的健康问题。

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.