Int Urogynecol J (2006) 17: 631635

DOI 10.1007/s00192-006-0085-y

ORIGINA L ARTI CLE

Hung-Yen Chin . Min-Chi Chen . Yu-Hung Liu .

Kuo-Hwa Wang

Postpartum urinary incontinence: a comparison of vaginal

delivery, elective, and emergent cesarean section
Received: 7 October 2005 / Accepted: 3 February 2006 / Published online: 28 March 2006
# International Urogynecology Journal 2006

Abstract The aim of this study was to assess the impact of

delivery on the pelvic floor and whether cesarean section
(C/S) can prevent pelvic floor injury. Five hundred thirty
nine women were divided into three groups according to
the delivery method adopted: elective C/S, emergent C/S,
and vaginal delivery. A urinary incontinence questionnaire
survey was conducted around 1 year postpartum. Emergent
C/S may be a major risk factor for postpartum urinary
incontinence and interfere with the benefit of elective C/S
for preventing pelvic floor injury. Hence, not all C/S
deliveries can reduce the likelihood of postpartum urinary
incontinence. The key lies in whether the C/S is performed
before labor.
Keywords Elective cesarean section . Emergent cesarean
section . Vaginal delivery . Stress urinary incontinence

H.-Y. Chin . Y.-H. Liu

Department of Obstetrics and Gynecology,
Chang Gung Memorial Hospital,
222 Mai-Chin Rd.,
Keelung, Taiwan, R.O.C.
M.-C. Chen
Department of Public Health and Biostatistics Consulting
Center, School of Medicine, Chang Gung University,
Kweishan, Taiwan, R.O.C.
K.-H. Wang (*)
Section of Urogynecology, Songshan Armed Forces General
Hospital and Department of Biology and Anatomy,
National Defense Medical Center,
131 Jian-Kang Rd.,
105, Taipei, Taiwan, R.O.C.
e-mail: Kuohwaw@yahoo.com
Tel.: +886-2-24313131
Fax: +886-2-24328040

Introduction
The controversy over cesarean section (C/S) vs vaginal
delivery with regard to pelvic floor trauma has long baffled
both caregivers and patients.
Damage to important muscles and nerves of the pelvic
floor is primarily attributable to vaginal delivery [2].
Numerous reviews have been published summarizing the
detrimental effects of childbirth on the pelvic floor, all
concluding that C/S may be more protective. However,
these commonly held conceptions have been challenged in
recent years [3]. Cesarean section cannot guarantee
complete protection against injury to the pelvic floor
because pregnancy itself has been shown to increase the
prevalence of urinary incontinence due to the impact of
mechanical compression on the pelvic floor [46]. Moreover, some recent studies have reported that there was no
significant difference in the level of genuine stress
incontinence between C/S and vaginal delivery [7].
The aim of this study is to compare the impact of
different delivery methods on the pelvic floor and to assess
whether C/Ss, both emergent and elective, would offer
protection against pelvic floor injury during delivery.

Materials and methods

Urinary incontinence is defined by the International
Continence Society (ICS) as involuntary urine loss due to
increasing abdominal pressure, which constitutes a social
or hygienic problem [8]. Urinary incontinence is the result
of pelvic floor dysfunction, which may be associated with
pregnancy and childbirth. A retrospective study was
conducted between January 2000 and November 2002 to
investigate whether C/S could reduce the prevalence of
urinary incontinence and to compare the effect of different
delivery methods on the pelvic floor. Our database

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contained medical records of 5,253 pregnant women.

However, just 539 cases were included in this study. All
these women were nulliparous and at term (gestational age
more than or equal to 37 weeks) with a single living fetus.
Other inclusion criteria were no history of urinary tract
abnormalities or previous urinary incontinence, no prior
surgery of the pelvic floor, and no medication that would
affect urinary continence. Pregnancy complications and a
high risk of preterm labor constituted the exclusion criteria.
Furthermore, our records focused on a time period around
1 year after the first delivery or before a second pregnancy,
during which urinary incontinence was still persistent. We
chose the patients around 1 year after delivery because the
situations of urinary incontinence would become more or
less the same by then, and their responses to our questions
would not be affected by another pregnancy or poor
memory.
For the C/S group, 116 patients underwent emergency C/
S, which means that the patients had protraction or arrest
disorder in the active phase of labor course and then went
on to C/S. Protraction was defined as a slowing down of
cervical dilatation of less than 1.2 cm/h or descent of less
than 1 cm/h for nulliparous. The criteria of arrest include a
complete cessation of dilatation for 2 h with no cervical
change or the absence of fetal descent for 1 h. Our
management approach to abnormal labor patterns followed
that of Cohen and Friedman and Cunningham et al. [9, 10],
and all of our emergent C/S cases received good
augmentation and had adequate uterine contraction before
the C/S decision was made.
The remaining 243 patients in the C/S group were given
an elective cesarean, which means that these patients,
having no uterine contraction detected by the patients
themselves or fetal monitor, chose to undergo scheduled C/
S owing to conditions such as voluntary, breech, transverse
lie, or previous uterine surgery.
In the vaginal delivery group, which serves as the control
of this study, all 180 patients received adequate augmentation, incidental epidural anesthesia, and routine episiotomy
during delivery. Patients who received vacuum or instrument delivery and had perineal body laceration higher than
the second degree were excluded.
A questionnaire survey was conducted over the
telephone to inquire about urinary incontinence symptoms
1 year postdelivery. All telephone interviews were made by
the same specialist nurse who was blinded to the delivery
Table 1 Demographic factors
of subjects (n=539)

Data are presented as meanSD

or frequency (percentage)
C/S Cesarean section, SUI
stress urinary incontinence
around 1 year postpartum
a
p<0.05 and is obtained using
the MannWhitney test or
chi-square test

method employed by the subjects. The questionnaire used

was adapted from a previous study [11]. The original
research probed into the frequency, severity, and impact of
incontinence on normal daily activities. Nevertheless, this
study focused mainly on exploring the correlation between
delivery method and incidence of incontinence. Therefore,
the analysis on severity of urinary incontinence and its
impact on life quality was beyond the scope of this study,
and questions on these aspects were omitted.
Data regarding pregnancy, delivery, and labor of every
patient were abstracted from the hospital records. The basic
data included history of preterm labor, illnesses suffered,
special medicines taken, maternal body weight before
pregnancy and before delivery, indication of C/S, body
weight and head circumference of baby delivered, and use
of instruments during delivery.
The data were analyzed by Statistical Package for Social
Sciences (SPSS, version 8.0) and presented as meanSD or
frequency followed by percentage (Table 1). A p value less
than 0.05 was considered statistically significant. The chisquare test was used to examine the relationship between
urinary incontinence and delivery methods. The Mann
Whitney test was employed to compare the differences in
demographic variables between the two groups because the
observations of the nonincontinent group were not
normally distributed (Table 1). The significant factors
were further examined simultaneously using multiple
logistic regression, and the relationship between risk
factors and the possibilities of urinary incontinence was
presented in terms of odds ratios (ORs) (Table 2).

Results
Among the 539 deliveries over the 3-year study period
(20002002), 18 (5.01%) patients in the C/S group and 13
(7.22%) patients in the spontaneous vaginal delivery group
reported postpartum urinary incontinence. In the C/S
group, 13 (11.21%) patients in the emergency C/S group
and 5 (2.06%) patients in the elective C/S group reported
postpartum urinary incontinence.
Among those who reported postpartum urinary incontinence, 26 patients experienced labor (8.8% in the labor
group), including 13 patients who had vaginal delivery and
13 patients who had emergent C/S.

Risk factors

SUI (n=31)

Non-SUI (n=508)

Maternal age (year)

Babys body weight (g)
Babys head circumference (cm)
Maternal BMI before pregnancy
Maternal BMI before delivery
Delivery method
Elective C/S
Emergent C/S
Vaginal delivery

30.585.28
3,234449.30
33.321.64
22.583.95
28.223.76

28.35.16
3,122477.23
33.661.66
21.163.50
27.343.9

0.013a
0.27
0.16
0.035a
0.128

5 (2.06%)
13 (11.21%)
13 (7.22%)

238 (97.94%)
103 (88.79%)
167 (92.78%)

0.001a

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Table 2 Statistical analysis using multiple logistic regression
Risk factor
Maternal age
BMI before pregnancy
Delivery method
Vaginal delivery
Elective C/S
Emergent C/S

OR

1.081
1.097

0.040*
0.049*

1
0.200
1.011

0.004*
0.98

Maternal age and BMI before pregnancy are taken as

continuous variables, whereas Delivery method is categorical and
vaginal delivery is treated as the control group
*p<0.05

Table 1 shows the comparisons in demographic

variables between the group with and without urinary
incontinence. As can be seen, there exists a strong
association between delivery method and the possibility
of urinary incontinence (p=0.001). The percentages of
those having urinary incontinence differed between the
three groupsthe lowest (2.06%) in the elective C/S
group, the highest (11.21%) in the emergent C/S group.
There was a significant difference in the maternal age and
body mass index (BMI) before pregnancyolder in the
urinary incontinent group than in the nonincontinent group
(30.58 vs 28.3, p=0.013) and larger BMI in the urinary
incontinent group than in the nonincontinent group (22.58
vs 21.16, p=0.035). However, there was no significant
difference between the two groups in terms of maternal
body height, body weight before pregnancy, body weight
before delivery, BMI before delivery, difference in body
weight before pregnancy and before delivery, as well as
body weight and head circumference of the newborn.
The significant factors identified in Table 1 were
analyzed using a multiple logistic model, and the results
are displayed in Table 2. As can be seen, an older maternal
age and higher BMI prior to pregnancy increase slightly the
risk of urinary incontinence (ORs=1.081 and 1.097, with p
values 0.040 and 0.049, respectively). After adjusting for
maternal age and BMI, the risk of urinary incontinence
becomes similar for the vaginal delivery and the emergent
C/S groups (OR=1.011, p=0.98). In contrast, the risk of
urinary incontinence in the elective C/S group is
significantly lower than that in the vaginal delivery group
(OR=0.200, p=0.004). When vaginal delivery and emergent C/S were further combined, it was found that the risk
in the elective C/S group was still significantly lower than
that of the combined group with OR=0.200 and p=0.001
(not shown in Table 2). In summary, the possibility of
postpartum urinary incontinence was similar in the vaginal
delivery and the emergent C/S groups, while the risk of
postpartum urinary incontinence in the elective C/S group
was significantly lower than the other two groups.

Discussion
The pathophysiology of urinary incontinence following
pregnancy remains unclear and have been reported to be
caused by increased incidence of bladder instability [12,
13], higher progesterone levels that induce a reduction in
estrogen receptor concentration [14], modification of the
anatomic relation between the bladder and the enlarged
uterus, decreased tensile strength of the fascia and bladder
neck anchoring system [15], congenital weakness of pelvic
floor supports, and overloaded urethrovesical unit in obese
women [16, 17]. In general, postpartum urinary incontinence may result from a combination of factors described
above.
In addition to the pregnancy itself, could delivery be a
critical event or present a major risk factor? Numerous
obstetric factors may contribute to the risk of urinary
incontinence, including birth weight, fetal head circumference, episiotomy, degree of trauma, mode of delivery and
maternal age at the time of delivery, maternal BMI during
delivery or prior to pregnancy, and parity. At the same time,
many surveys and studies have reported the relationship
between obstetric factors such as ultrasonography of the
bladder neck [13, 18, 19], neurophysiologic examinations
of the pudendal nerve [2022] and urodynamic study for
urethral closure pressure [21], and the risk of subsequent
incontinence. However, the conclusions derived from the
findings so far remain conflicting [2325].
It is interesting to note that there were significant
differences in maternal BMI prior to pregnancy and
maternal age between the incontinent and nonincontinent
groups (Table 1). However, there were no statistical
differences in maternal BMI before delivery, or the
difference in weight prior to pregnancy and before delivery.
Therefore, even if the maternal body weight only increases
moderately, the primary BMI (before pregnancy) would be
still a risk factor for postpartum urinary incontinence.
However, there are yet no standard values of BMI for
predicting the possibility of C/S. In addition, older
maternal age was found to increase the risk of urinary
incontinence in our study. Although ageing is primarily a
risk factor for urinary incontinence, it does not mean that
the older the woman at delivery, the more likely she would
have postpartum urinary incontinence.
In our study, the general incidence of postpartum urinary
incontinence after C/S in nulliparous women was consistent with other reports [7]. The C/S group had a lower
percentage rate of postpartum urinary incontinence (5% in
C/S group vs 7.2% in vaginal delivery group, p=0.329), but
there was no statistically significant difference between the
C/S and the vaginal delivery groups. This shows that the
protective effect of the pelvic floor with both types of C/S
considered was not statistically better than that of vaginal
delivery. On the contrary, after adjusting for other
covariates, it was found that the postpartum urinary stress
incontinence rate was significantly different among the
emergent C/S, elective C/S, and vaginal delivery groups
(p=0.001), as shown in Table 1. This would mean that the
risk for the C/S group was lower, but not significantly less

634

than the mean risk until we separated the elective C/S

group from the emergent C/S group. Thus, emergent C/S
may be a major risk factor for postpartum urinary
incontinence and interfere with the benefit of an elective
C/S for the prevention of pelvic floor injury.
Does the push power resulting from uterine contraction
contribute to urinary incontinence? Sultan et al. [22]
reported that women who had had a C/S after the onset of
labor were at risk of developing pudendal nerve damage,
whereas those who had an elective C/S were not. As seen in
Table 2, the possibility of postpartum urinary incontinence
for elective C/S was significantly lower than for emergent
C/S, also known as C/S after labor. The effect of the
strength of uterine contraction between the emergent C/S
group and the vaginal delivery group was similar, except
that the fetus had descended completely and passed
through the pelvic floor in the vaginal delivery group but
not in the emergent C/S group. This would indicate a
higher possibility of postpartum urinary incontinence
among the group who experienced labor. Hence, the key
to the best protection against postpartum urinary incontinence seems to lie in the timing of the C/S; that is, the C/S
has to be performed before labor or uterine contraction is
experienced. From this, it can be concluded that not all C/S
deliveries can be considered as a superior alternative for
pelvic floor protection, which would decrease the likelihood of postpartum urinary incontinence.
There are some limitations in our study that should be
noted. First, there is a big difference in the sample
population of the two groups (C/S vs vaginal delivery,
359 vs 180). The small sample population of the vaginal
delivery group is because a lot of women in the vaginal
delivery group who received routine vacuum extraction to
help the fetal heads pass through the vaginal outlet due to
general weakness or poor pushing power were excluded.
Use of instrument during delivery and preterm was
employed as a exclusion criterion to ensure that the vaginal
delivery group without instrumental assistance will serve
as the pure control to distinguish the benefit between
elective C/S and emergent C/S, and to avoid the
confounding effect of preterm labor during pregnancy on
the pelvic floor. Second, some cases in our data, in
particular those subjects who were immigrants, were lost in
the follow-up owing to problems such as language barrier
or shifting of residence. The majority of these lost cases
were in the vaginal delivery group. Third, many patients
are referred to our hospital for surgeries. Hence, our
database contains a greater proportion of surgical cases,
and this accounts for the relatively greater number of C/S
subjects. The small sample population of the vaginal
delivery group constitutes a weakness in this study, which
may undermine the validity of our findings.
The idea of elective C/S offering protection against
pelvic floor injury has attracted much attention in recent
years [26]. Although our results find support for such, not
all C/S deliveries can be regarded as a superior alternative
method for decreasing the likelihood of postpartum urinary
incontinence. The key lies in whether the C/S is performed
before labor. A longer duration of follow-up and a larger

sample size should be required to evaluate the efficacy of

prevention of pelvic floor by elective C/S in the future.

References
1. Thorp JM, Norton PA, Wall LL, Kuller JA, Eucker B, Wells E
(1999) Urinary incontinence in pregnancy and the puerperium:
a prospective study. Am J Obstet Gynecol 181:266273
2. Foldspang A, Mommsens S, Djurhuus JC (1999) Prevalent
urinary incontinence as a correlate of pregnancy, vaginal
childbirth, and obstetric techniques. Am J Public Health 89
(2):209212
3. Rortvei G, Daltveit A, Anne K, Hannestad YS, Hunskaar S
(2003) Urinary incontinence after vaginal delivery or cesarean
section. N Engl J Med 348:900907
4. Foldspang A, Mommsen S, Djurhuus JC (1999) Prevalent
urinary incontinence as a correlate of pregnancy, vaginal
childbirth, and obstetric techniques. Am J Public Health
89:209212
5. Mant J, Painter R, Vessey M (1997) Epidemiology of genital
prolapse: observations from the Oxford Family Planning
Association Study. Br J Obstet Gynaecol 104:579585
6. Faundes A, Guarisi T, Pinto-Neto AM (2001) The risk of
urinary incontinence of parous women who delivered only by
cesarean section. Int J Gynecol Obstet 72:4146
7. Demirci F, Ozden Z, Alpay E, Demirci ET, Ayas S (2001) The
effects of vaginal delivery and cesarean section on bladder neck
mobility and stress urinary incontinence. Int Urogynecol J
12:129133
8. International Continence Society (2002) The standardization of
terminology of lower urinary tract function: report from the
standardization sub-committee of the International Continence
Society. Neurourol Urodyn 21:167178
9. Cohen W, Friedman EA (1983) Management of labor.
University Park, Baltimore
10. Cunningham FG, MacDonald PC, Gant NF, Leveno KJ,
Gilstrap LC, Hankins GDK, Clark SL (1997) Williams
obstetrics, 20th edn. Appleton & Lange, Norwalk
11. Farrell SA, Allen VM, Baskett TF (2001) Parturition and
urinary incontinence in primiparas. Obstet Gynecol 97:350356
12. Cutner A, Cardozo LD, Beness CJ (1992) Assessment of
urinary symptoms in the second half of pregnancy. Int
Urogynecol J 3:3032
13. Jennifer KK, Robert MF (1998) Is antenatal bladder neck
mobility a risk factor for postpartum stress incontinence? Br J
Obstet Gynecol 105:13001307
14. Miodrag A, Casleden CM, Vallance TR (1988) Sex hormones
and the female lower urinary tract. Drugs 36:491504
15. Landon CR, Crofts CE, Smith ARB, Trowbridge EA (1990)
Mechanical properties of fascia during pregnancy: a possible
factor in development of stress incontinence of urine. Contemp
Rev Obstet Gynecol 2:4046
16. Bump RC (1993) Racial comparisons and contrasts in urinary
incontinence and pelvic organ prolapse. Obstet Gynecol
81:421425
17. Dwyer PL, Lee ETC, Hay DM (1988) Obesity and urinary
incontinence in women. Br J Obstet Gynecol 95:9196
18. Pschers U, Schaer G, Anthuber C, Delancey JOL, Schussler B
(1996) Changes in vesical neck mobility following vaginal
delivery. Obstet Gynecol 88:10011006
19. Wijma J, Potters AEW, de Wolf BTHM, Tinga DJ, Aarnoudse
JG (2003) Anatomical and functional changes in the lower
urinary tract following spontaneous vaginal delivery. BJOG
110:658663
20. Snook SJ, Badenoch DF, Tiptaft RC, Swash M (1985) Perineal
nerve damage in genuine stress incontinence. An electrophysiologic study. Br J Urol l57:422426
21. Smith AR, Hosker GL, Warrell DW (1989) The role of
pudendal nerve damage in the aetiology of genuine stress
incontinence in women. Br J Obstet Gynaecol 96:2932

635
22. Sultan AH, Kamm MA, Hudson CN (1994) Pudendal nerve
damage during labor: prospective study before and after
childbirth. Br J Obstet Gynaecol 101:2228
23. Chaliha C, Bland JM, Monga A, Stanton SL, Sultan AH (2000)
Pregnancy and delivery: an urodynamic viewpoint. BJOG
107:13541359
24. Wilson PD, Herbison RM, Herbison GP (1996) Obstetric
practice and the prevalence of urinary incontinence three
months after delivery. Br J Obstet Gynaecol 103:154161

25. Meyer S, Shreyer A, Grandi DE, Hohlfeld P (1998) The effects

of birth on urinary continence mechanisms and other pelvic
floor characteristics. Obstet Gynecol 42:613618
26. Groutz A, Rimon E, Peled S, Gold R, Pauzner D, Lessing JB,
Gordon D (2004) Cesarean section: does it really prevent the
development of postpartum stress urinary incontinence? A
prospective study of 363 women one year after their first
delivery. Neurourol Urodyn 23(1):26

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