Cesarean section upon request: is it appropriate for everybody?

The request for cesarean section without medical indication has become one of the dilemmas faced by the obstetrician. Most recent studies that compare vaginal delivery with elective cesarean section find them equally safe. This comparison is lacking in the option of trial of labor, which may result in an assisted vaginal delivery or intrapartum cesarean section, both with increased morbidity and mortality for the mother and newborn. When considering elective cesarean section, the obstetrician has to take into account improved anesthetic techniques and the decrease in morbidity and mortality after cesarean section with the trend toward patient autonomy to decide on her own treatment. On the other hand, the obstetrician has to advise his patient of the best treatment with respect to possible complications in future pregnancies, such as placental complications and increased morbidity and mortality resulting from repeated cesarean sections. The advantage of cesarean section for pelvic floor protection does not exist after three consecutive cesarean sections and equals the rate of urinary incontinence after consecutive three vaginal deliveries. In countries such as ours, where most women wish for several children, the risk-benefit balance is toward repeated spontaneous vaginal deliveries.     

Maternal and neonatal morbidity after elective repeat Cesarean delivery versus a trial of labor after previous Cesarean delivery in a community teaching hospital.

OBJECTIVE: To compare maternal and fetal outcomes after elective repeat Cesarean section versus a trial of labor in women after one prior uterine scar. STUDY DESIGN: All women with a previous single low transverse Cesarean section delivered at term with no contraindications to vaginal delivery were retrospectively identified in our database from January 1995 to October 1998. Outcomes were first analyzed by comparing mother-neonate dyads delivered by elective repeat Cesarean section to those undergoing a trial of labor. Secondarily, outcomes of mother-neonatal dyads who achieved a vaginal delivery or failed a trial of labor were compared to those who had elective repeat Cesarean delivery. RESULTS: Of 1408 deliveries, 749/927 (81%) had a successful vaginal birth after a prior Cesarean delivery. There were no differences in the rates of transfusion, infection, uterine rupture and operative injury when comparing trial of labor versus elective repeat Cesarean delivery. Neonates delivered by elective repeat Cesarean delivery were of earlier gestation and had higher rates of respiratory complications (p < 0.05). Mother-neonatal dyads with a failed trial of labor sustained the greatest risk of complications. CONCLUSION: Overall, neonatal and maternal outcomes compared favorably among women undergoing a trial of labor versus elective repeat Cesarean delivery. The majority of morbidity was associated with a failed trial of labor. Better selection of women likely to have a successful vaginal birth after a prior Cesarean delivery would be expected to decrease the risks of trial of labor.     

Vaginal birth after cesarean delivery in the twin gestation

The pregnancy outcomes of 56 women with a twin gestation and a prior cesarean birth were analyzed to determine whether a trial of labor was a reasonable consideration. Of these patients, 31 (55%) underwent an elective repeat cesarean delivery and 25 (45%) attempted vaginal delivery. Of those who attempted vaginal delivery, 18 (72%) were vaginally delivered of both infants. The dehiscence rate among women with twin pregnancies who attempted a trial of labor was 4% compared with 2% in women with singleton pregnancies. There were no significant differences in maternal or neonatal morbidity or mortality rates in trial of labor versus no trial of labor groups. We conclude in this limited population that a trial of labor in a twin gestation after a previous cesarean delivery appears to be a reasonable consideration. The usual safeguards for attempted vaginal delivery in the twin gestation should be followed.     

Balancing the risks of planned cesarean section and trial of vaginal delivery for the mature, selected, singleton breech presentation

The experience of mature, singleton, vaginal breech delivery over the last decade in our hospital is reviewed. This constitutes the largest series of breech delivery reported for over twelve years. Unlike all but two previous reports, we analyze our results by management policy; elective cesarean section, trial of vaginal breech delivery and cesarean section as soon as the diagnosis of breech delivery was made on labor ('expedite' cesarean operations). Six intrapartum or neonatal deaths occurred among 613 patients selected for trial of vaginal delivery--a rate of one per cent. There were none following 217 elective or 69 expedite cesarean sections. A detailed review of the literature over the last decade confirms that trial of vaginal delivery is more dangerous to the fetus and results in about one perinatal death of a normally formed infant in 200 deliveries. Apgar scores were slightly lower following trial of vaginal delivery and there were more irritable or injured babies in this group. The last intrapartum or neonatal death occurred in 1981. However, the elective cesarean section rate has increased from 14 to 33 per cent over this time period. Similarly the rate of failed trial of vaginal breech delivery has increased from 15 to 31 per cent. The proportion of failed trials was highest where the fetus was large but clinicians were poor at estimating fetal weight. Decision theory is used to examine the maternal utility of trial of vaginal breech delivery versus elective cesarean section when the intrapartum cesarean rate rises to these levels. It is shown that, from the point of view of maternal mortality and morbidity in the current pregnancy, trial of vaginal delivery maybe the more dangerous maternal option. Thus a low threshold for cesarean section in labor leads to greater fetal safety at the mother's expense. It is nevertheless concluded that maternal attitude and the long-term effects of a uterine scar should be considered in the final decision.     

Once a pregnancy, always a cesarean? Rationale and feasibility of a randomized controlled trial

Although vaginal delivery has long been assumed to be the preferred route of delivery in women who have not had a prior cesarean delivery, some have recently advocated that women be offered the option of elective, primary cesarean delivery in all pregnancies. Available outcome data, however, do not permit ready comparison of these alternate plans for delivery. Important maternal outcomes include short-term complications such as death, bleeding, infection, and damage to pelvic organs as well as long-term effects on future pregnancies, fecal and urinary incontinence, and pelvic organ prolapse. Important neonatal outcomes include asphyxic and traumatic birth injury, infection, respiratory complications, and stillbirth. To weigh the relative merits of elective primary cesarean delivery and a trial of labor, a randomized controlled trial is needed. Such a trial would be both ethical and feasible.     

Maternal and neonatal morbidity after elective repeat Cesarean delivery versus a trial of labor after previous Cesarean delivery in a community teaching hospital

Objective: To compare maternal and fetal outcomes after elective repeat Cesarean section versus a trial of labor in women after one prior uterine scar.

Study design: All women with a previous single low transverse Cesarean section delivered at term with no contraindications to vaginal delivery were retrospectively identified in our database from January 1995 to October 1998. Outcomes were first analyzed by comparing mother–neonate dyads delivered by elective repeat Cesarean section to those undergoing a trial of labor. Secondarily, outcomes of mother–neonatal dyads who achieved a vaginal delivery or failed a trial of labor were compared to those who had elective repeat Cesarean delivery.

Results: Of 1408 deliveries, 749/927 (81%) had a successful vaginal birth after a prior Cesarean delivery. There were no differences in the rates of transfusion, infection, uterine rupture and operative injury when comparing trial of labor versus elective repeat Cesarean delivery. Neonates delivered by elective repeat Cesarean delivery were of earlier gestation and had higher rates of respiratory complications (p?<?0.05). Mother–neonatal dyads with a failed trial of labor sustained the greatest risk of complications.

Conclusion: Overall, neonatal and maternal outcomes compared favorably among women undergoing a trial of labor versus elective repeat Cesarean delivery. The majority of morbidity was associated with a failed trial of labor. Better selection of women likely to have a successful vaginal birth after a prior Cesarean delivery would be expected to decrease the risks of trial of labor.     

Elective repeat cesarean delivery versus trial of labor: a meta-analysis of the literature from 1989 to 1999

OBJECTIVE: The aim of this study was to compare a trial of labor with elective repeat cesarean delivery among women with previous cesarean delivery. STUDY DESIGN: We searched MEDLINE and EMBASE databases from 1989 through 1999 with the following terms: vaginal birth after cesarean delivery, trial of labor, trial of scar, and uterine rupture. We included all controlled trials from developed countries in which the control group had been eligible for a trial of labor. Outcomes of interest were uterine rupture, hysterectomy, maternal febrile morbidity, maternal mortality, 5-minute Apgar score <7, and fetal or neonatal mortality. We computed pooled odds ratios for each outcome. RESULTS: The search strategy identified 52 controlled studies, 37 of which were excluded because many of the control subjects were not eligible for a trial of labor. Fifteen studies with a total of 47,682 women were included. Uterine rupture occurred more frequently among women undergoing a trial of labor than among those undergoing elective repeat cesarean delivery (odds ratio, 2.10; 95% confidence interval, 1.45-3.05). There was no difference in maternal mortality risk between the 2 groups (odds ratio, 1.52; 95% confidence interval, 0.36-6.38). Fetal or neonatal death (odds ratio, 1.71; 95% confidence interval, 1.28-2.28) and 5-minute Apgar scores <7 (odds ratio, 2.24; 95% confidence interval, 1.29-3.88) were more frequent in the trial of labor group than in the control group. Mothers undergoing a trial of labor were less likely to have febrile morbidity (odds ratio, 0.70; 95% confidence interval, 0.64-0.77) or to require transfusion (odds ratio, 0.57; 95% confidence interval, 0.42-0.76) or hysterectomy (odds ratio, 0.39; 95% confidence interval, 0.27-0.57). CONCLUSION: A trial of labor may result in small increases in the uterine rupture rate and in fetal and neonatal mortality rates with respect to elective repeat cesarean delivery. Maternal morbidity, including febrile morbidity, and the need for transfusion or hysterectomy may be reduced with a trial of labor.     

The counselling of patient with prior C-section

A trial of labor after prior cesarean delivery is associated with a greater perinatal risk than is elective repeated cesarean delivery without labor, although absolute risks are low. Information and counselling aim to estimate specific risks and to balance these risks according to individual factors. Therefore, the physician has to answer two questions: (i) which would be the probability of successful vaginal delivery? (ii) which would be the risk of uterine rupture with a trial of labor? The risk factors for failure of trial of labor are: increased maternal age, obesity, and fetal macrosomia. The risk factors for uterine rupture are: increased maternal age, postpartum fever after the previous cesarean delivery, short interdelivery interval, history of at least two previous cesarean deliveries, and a history of classical incision. Conversely, other factors are of good prognosis: a prior vaginal delivery and, particularly, a prior VBAC (Vaginal Birth After Caesarean) are associated with a higher rate of successful trial of labor compared with patients with no prior vaginal delivery; ultrasonographic measurement of the lower uterine segment thickness>3.5 mm has an excellent negative predictive value for the risk of uterine defect. Finally, the wish for additional pregnancies following a cesarean section must be considered as an argument in favour of a trial of labor after accounting for the increasing risks correlated with repeated elective cesarean deliveries.     

The Maternal-Fetal Medicine Unit cesarean registry: trial of labor with a twin gestation

OBJECTIVE: The purpose of this study was to identify the success rates and risks in women with a twin pregnancy who attempt a trial of labor after cesarean delivery. STUDY DESIGN: Cases were identified in the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network's Cesarean Registry with a woman with a twin pregnancy who had had at least 1 previous cesarean delivery. RESULTS: During the study period (1999-2002), 412 women fulfilled the study criteria, and 226 women had elective repeat cesarean delivery. Of the 186 women (45.1% of total) who attempted a trial of labor, 120 women were delivered successfully (success rate, 64.5%), and 66 women (35.5%) had a failed trial of labor. Thirty of the failed trials of labor involved a vaginal delivery for twin A and cesarean delivery for twin B. Women who attempted a trial of labor with twins had no increased risk of transfusion, endometritis, intensive care unit admissions, or uterine rupture when compared with elective repeat cesarean delivery. Fetal and neonatal complications were uncommon in either group at>or=34 weeks of gestation. CONCLUSION: A trial of labor with twins after previous cesarean delivery does not appear to increase maternal morbidity. Perinatal morbidity is uncommon at>or=34 weeks of gestation.     

Deliveries after cesarean birth in two Asian university hospitals

The task force of the consensus conference on cesarean birth of the National Institutes of Health, USA, has recommended substituting a trial of labor and vaginal delivery for elective repeat cesarean section in selected women. This paper assesses the benefits and risks associated with that recommendation using data from two Asian teaching hospitals, one in Jakarta, Indonesia and the other in Colombo, Sri Lanka. Data recorded on the Maternity Record Form designed by the International Fertility Research Program and the International Federation of Gynecology and Obstetrics were used for analysis. Consistent findings were derived from the two hospitals, in spite of the different medical care delivery systems in their countries. No significant increase in maternal and infant mortality and morbidity were associated with women having vaginal delivery subsequent to cesarean birth as compared to those with repeat cesarean section. Savings in medical cost were considerable in the former group.     

Route of breech delivery and maternal and neonatal outcomes.

OBJECTIVE: To compare maternal and neonatal outcomes in elective cesarean vs. attempted vaginal delivery for breech presentation at or near term. METHODS: We reviewed the maternal and neonatal charts of all singleton breech deliveries of at least 35 weeks' gestation or 2000 g delivered between 1986 and 1997 at our institution. Patients delivered by elective cesarean were compared to those attempting a vaginal delivery. The neonatal outcomes analyzed were: corrected mortality; Apgar scores less than 7 at 5 min; abnormal umbilical cord blood gases; birth trauma; and admissions to the intensive care nursery. Maternal morbidity was also assessed and compared. RESULTS: Of 848 women meeting criteria for evaluation, 576 were delivered by elective cesarean while 272 attempted a vaginal delivery. Of 272 women undergoing a trial of labor, 203 (74.6%) were delivered vaginally, while 69 (25.4%) failed an attempt at vaginal delivery and underwent a cesarean. When comparing patients delivered by elective cesarean with those attempting a vaginal delivery, no significant differences were noted in neonatal outcomes. However, maternal morbidity was higher among women delivered by cesarean, regardless of the indications for the procedure. Similar neonatal and maternal results were noted when nulliparous patients were analyzed separately. CONCLUSIONS: Cesarean delivery of selected near-term infants presenting as breech is associated with increased maternal morbidity without corresponding improvement in neonatal outcomes.     

Trial of labor or repeat cesarean delivery in women with morbid obesity and previous cesarean delivery

OBJECTIVE: Assess effects of body mass index (BMI) on trial of labor after previous cesarean delivery and determine whether morbidly obese women have greater maternal and perinatal morbidity with trial of labor compared with elective repeat cesarean delivery. METHODS: Secondary analysis from a prospective observational study included all term singletons undergoing trial of labor after previous cesarean delivery. Body mass index groups were as follows: normal 18.5-24.9, overweight 25.0-29.9, obese 30.0-39.9, morbidly obese 40.0 kg/m2 or greater, and were compared for failure and maternal and neonatal morbidities. The morbidly obese trial of labor and elective repeat cesarean delivery were compared for maternal and neonatal morbidities. Multivariable logistic regression analysis controlled for confounding variables. RESULTS: There were 14,142 trial of labor participants and 14,304 elective repeat cesarean delivery participants. Increasing BMI was directly associated with failed trial of labor after previous cesarean delivery: from 15.2% in normal weight (1,344) to 39.3% in morbidly obese (1,638), with combined risk of rupture/dehiscence increasing from 0.9% to 2.1% in morbidly obese women. Among morbidly obese women, trial of labor carried greater than five-fold risk of uterine rupture/dehiscence (2.1% versus 0.4%), almost a two-fold increase in composite maternal morbidity (7.2% versus 3.8%) and five-fold risk of neonatal injury (1.1% versus 0.2%) (fractures, brachial plexus injuries, and lacerations), but no neonatal encephalopathy. Morbidly obese women failing a trial of labor had six-fold greater composite maternal morbidity than those undergoing a successful trial of labor (14.2% versus 2.6%). CONCLUSION: Body mass index correlates with outcomes in trial of labor after previous cesarean delivery. Morbidly obese women undergoing a trial of labor were at increased risk for failure. Increased BMI was associated with greater composite morbidity and neonatal injury compared with elective repeat cesarean delivery, but absolute morbidities were small. Increased risks should be considered before trial of labor after previous cesarean delivery. LEVEL OF EVIDENCE: II-2.     

Delivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF)

The primary cause of uterine scars is a previous cesarean. In women with a previous cesarean, the risks of maternal complications are rare and similar after a trial of labor after cesarean (TOLAC) and after an elective repeat cesarean delivery (ERCD), but the risk of uterine rupture is higher with TOLAC (level of evidence [LE]2). Maternal morbidity in women with previous cesareans is higher when TOLAC fails than when it leads to successful vaginal delivery (LE2). Although maternal morbidity increases progressively with the number of ERCD, maternal morbidity of TOLAC decreases with the number of successful previous TOLAC (LE2). The risk-benefit ratio considering the risks of short- and long-term maternal complications is favorable to TOLAC in most cases (LE3).     

Caesarean Section on Maternal Request: Risks and Benefits in Healthy Nulliparous Women and Their Infants

ObjectiveTo determine the risks and benefits of an elective Caesarean section (CS) at term in healthy nulliparous women.MethodsWe conducted a population-based cohort study of deliveries between 1994 and 2002. Using bivariate and multivariable techniques, we compared maternal and neonatal outcomes in healthy nulliparous women who had undergone elective pre-labour CS (using breech presentation as a surrogate) with those in women who had undergone spontaneous labour with anticipated vaginal delivery (SL) at full term.ResultsThere were 1046 deliveries in the pre-labour CS group and 38 021 in the SL group. Life-threatening maternal morbidity was similar in each group. Life-threatening neonatal morbidity was decreased in the CS group (RR 0.34; 99% CI 0.12 to 0.97). Subgroup analysis of the SL group by mode of delivery demonstrated the increased neonatal risk was associated with operative vaginal delivery and intrapartum CS but not spontaneous vaginal delivery.ConclusionAn elective pre-labour Caesarean section in a nulliparous woman at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery. However, the 63% of women with spontaneous labour who achieved a spontaneous vaginal delivery would not have benefited from delivery by Caesarean section. Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum Caesarean section, as this may assist maternity caregivers in decision-making about childbirth. Further research is also needed to determine if these findings can be confirmed in a prospective study.     

Does cesarean section prevent mortality and cerebral ultrasound abnormalities in preterm newborns?

OBJECTIVE: Despite the increased use of the cesarean section (CS), the rates of cerebral palsy, a frequent consequence of brain damage, have remained stable over the last decades. Whether an actual decrease in cerebral palsy has been masked by increased survival of infants delivered by CS or not, remains undefined. To investigate the role of CS, we compared risks of mortality and brain damage, as defined by ultrasound (US) abnormalities, in preterm newborns by mode of delivery. METHODS: Information on fetal, maternal, and neonatal risk factors was collected from the paired clinical records of preterm newborns and mothers. Crude and adjusted odds ratios (OR) of mortality and ultrasound abnormalities, according to mode of delivery (i.e., vaginal, elective CS, and emergency CS) were calculated. All the analyses were controlled for possible confounding by indication. RESULTS: In newborns of gestational age <32 weeks, no effect of CS on cerebral US abnormalities was found (OR 0.71 and 0.73 for emergency CS and elective CS, respectively). None of the maternal and neonatal factors were associated with both cerebral US abnormalities and mode of delivery. Among newborns of gestational age >or=32 weeks, after controlling for known and potential confounders in a multivariate model, the adjusted ORs remained close to one for both elective CS and emergency CS. CONCLUSIONS: CS does not reduce overall mortality in preterm newborns. No protective effect of CS on US abnormalities was found after stratifying by gestational age and controlling for possible confounding. These results do not encourage the widespread use of CS in preterm labor.     

预防初次剖宫产指南对促进阴道试产的作用

剖宫产术是处理妊娠并发症和合并症、解决难产和宫内缺氧的重要手段。但近年剖宫产率的上升并未明显降低孕产妇和围产儿发病率及死亡率,相反增加了剖宫产术后并发症的发生率。文章分析剖宫产的风险,从孕期管理,个性化引产,提高助产技术,新产程的运用,胎儿监护的管理,臀位外倒转以及剖宫产后阴道试产等7个方面阐述有关预防剖宫产、促进阴道试产问题。     

Management of previous cesarean section

PURPOSE OF REVIEW: The management of cesarean sections causes much controversy among healthcare providers, patients, and insurers. A trial of vaginal birth after previous cesarean is reported to be a safe and practical method to reduce the rate of cesarean sections. The popularity of vaginal birth after previous cesarean has increased over the past two decades, but rates have recently started to decline again. This review will evaluate recent literature that might be responsible for this reversal in trend. RECENT FINDINGS: Earlier studies on previous cesarean section pregnancies focused primarily on the success rate of vaginal birth after previous cesarean, which is reported to be 60-80%. Recent large, retrospective, population-based cohort studies examined the maternal and neonatal safety of trial of labour compared with elective repeat cesarean delivery, and confirmed that the risks of uterine rupture and neonatal mortality were significantly increased after trial of labour, particularly when induced with prostaglandins. However, the absolute risk of adverse events remains small. The maternal and neonatal morbidity risk increases when vaginal birth after previous cesarean attempts fails, which emphasizes the importance of careful case selection. SUMMARY: Recent studies highlighted the risks of attempted vaginal birth after previous cesareans, especially when trials fail, but have not addressed the long-term risks of an elective repeat cesarean delivery. The assessment of treatment risks by observational studies is subject to bias, because the different treatment groups may not be comparable at the outset. In the absence of better data, the counselling of such women must currently be based on this evidence.     

Vaginal birth following two previous cesarean sections

OBJECTIVE: To evaluate the management of vaginal delivery among women with two previous cesarean sections. The maternal and fetal morbidities of this attitude were studied. SETTING: University hospital. DESIGN: Retrospective study made over 6 years, from January 1st 1990 to December 31st 1995. PATIENTS: Among 180 patients with two uterine scars, 96 patients with cephalic presentation and normal pelvic dimensions were allowed trial of labor. RESULTS: The rate of vaginal birth following trial of labor was 65.6%. Three patients had an uterine scar dehiscence; among them, one hysterectomy was performed for haemorrhage with uterine atony. Neonatal issue was always favorable. Twenty-two newborns had superior birthweights compared to those born from the preceding cesarean section. CONCLUSION: Trial of labor following two previous cesarean sections is acceptable in the majority of cases. It leads to a high vaginal delivery rate and low maternal and fetal morbidity.     

Vaginal birth after cesarean: to induce or not to induce

OBJECTIVE: Our purpose was to determine the impact of labor induction on both the success and safety of a trial of labor in women who are candidates for vaginal birth after cesarean. STUDY DESIGN: We performed a prospective observational analysis of 505 women consecutively presenting for delivery with a prior cesarean (September 1997-December 1999), of whom 236 (46.7%) underwent trial of labor. The following three cohorts were established: (1) repeat cesarean without trial of labor (n = 269), (2) spontaneous trial of labor (n = 179), and (3) induced trial of labor (n = 57). RESULTS: The vaginal delivery rate was significantly higher (77.1% vs 57.9%) in the spontaneous labor group compared with the induced labor group (odds ratio, 2.45; 95% confidence interval, 1.24-4.82; P =.008). Uterine scar separation occurred more frequently in the induced labor group (7%) than in the elective repeat cesarean group (1.5%) (odds ratio, 0.20; 95% confidence interval, 0.04-0.99; P =.034). CONCLUSION: Induction of labor in women attempting vaginal birth after cesarean is associated with a significantly reduced rate of successful vaginal delivery and an increased risk of serious maternal morbidity.     

Prevention of urinary and anal incontinence: role of elective cesarean delivery

PURPOSE OF REVIEW: Currently, prophylactic elective cesarean to prevent incontinence is being promoted without robust evidence supporting it, this has created confusion among health personnel [corrected]. Past research centered on defining the damaging effect of vaginal birth on continence whilst the limited research on elective cesarean considered it protective. Cesarean delivery has economic, obstetric, gynecological and psychosocial consequences, but incontinence is not uncommon with a persistent morbidity. There is confusion among health personnel about advocating elective cesarean delivery to prevent incontinence. Reviewing current research would facilitate obstetric thinking. RECENT FINDINGS: Multiplanar endosonography and three-dimensional magnetic resonance imaging scanning are reportedly better in delineating structural alterations in the continence mechanism following vaginal birth and could be applied to postcesarean incontinence. Incontinence can follow vaginal or elective cesarean delivery and the severity following either mode is comparable. Urinary incontinence can resolve, persist or start de novo and the primiparous prevalence is similar following cesarean or vaginal birth. Transient anal incontinence can manifest during pregnancy. Paradoxically, pelvic floor strengthening exercises are beneficial for pregnancy-related incontinence, yet urinary incontinence occurs in nulliparas notwithstanding a strong pelvic floor. SUMMARY: Improved imaging techniques should promote a better understanding of postcesarean incontinence. Since severe incontinence can occur after elective cesarean, its reportedly preventative role deserves more scrutiny. When incontinence occurs without labor, it is transient or shows exercise-related improvement; the role of elective cesarean delivery seems tenuous and needs careful evaluation. Current evidence does not support the routine use of elective cesarean to prevent incontinence so the delivery mode should continue to be dictated by obstetric considerations.