MOAD Trial.

5-10 years after first delivery, spontaneous vaginal birth and especially operative vaginal birth are associated with substantially higher odds of stress urinary incontinence and pelvic organ prolapse compared with cesarean delivery without labor.

QUESTION

How does mode of delivery affect pelvic floor disorder risk 5 to 10 years after first childbirth?

DESIGN

• Population: N=1,011 recruited 5 to 10 years after first delivery; median age 40yo; predominantly parous; evaluated at a single center.

• Intervention: Observational exposure to delivery mode, categorized across all births as cesarean delivery without labor, cesarean delivery during active labor, cesarean delivery after complete dilation, spontaneous vaginal birth, or operative vaginal birth.

• Comparison: Cesarean delivery without labor served as the reference group.

OUTCOMES

• Primary outcome: Pelvic organ prolapse to or beyond the hymen on examination.

  • Spontaneous VB vs CS with no labor: aOR 5.64 (95% CI: 2.16-14.70).

  • Operative VB vs CS with no labor: aOR 7.50 (95% CI: 2.70-20.87).

• Secondary outcomes:

  • Stress UI

    • Spontaneous VB vs CS with no labor: aOR 2.87 (95% CI: 1.49-5.52).

    • Operative VB vs CS with no labor: aOR 4.45 (95% CI: 2.14-9.27).

  • Overactive bladder symptoms:

    • Operative VB vs CS with no labor: aOR 4.89 (95% CI: 2.23-10.74).

  • Anal incontinence

    • Operative VB vs CS with no labor: aOR 2.22 (95% CI: 1.06-4.64).

  • CS after labor or after complete dilation did not significantly increase odds of pelvic floor disorders compared with cesarean delivery without labor.

  • Number needed to harm: ~8.9 spontaneous vaginal births or 6.8 operative vaginal births relative to cesarean delivery without labor result in one additional case of prolapse to or beyond the hymen.

QUIZ

1. Which anatomic injury is most strongly associated with long-term prolapse after operative vaginal delivery?
A. External anal sphincter tear
B. Urethral mucosal atrophy
C. Pubovisceral (pubococcygeus) muscle avulsion from the pubic bone
D. Cervical elongation

2. Why can advanced pelvic organ prolapse reduce apparent stress urinary incontinence symptoms on history?
A. Increased bladder capacity
B. Increased detrusor contractility
C. Increased estrogen effect on urethral smooth muscle
D. Urethral kinking or compression masking intrinsic sphincter weakness