Association Between Sexual Health and Delivery Mode

Abstract

IntroductionFemale sexual function changes considerably during pregnancy and the postpartum period. In addition, women's physical and mental health, endocrine secretion, and internal and external genitalia vary during these times. However, there are limited studies on the relationship between delivery and sexual function.AimThe present study aimed to demonstrate the association between sexual function and delivery mode.Methods
Mothers who delivered a single baby at term were recruited for the study, and 435 mothers were analyzed.Main Outcome MeasuresThe Female Sexual Function Questionnaire (SFQ28) scores and mothers' backgrounds were assessed at 6 months after delivery.ResultsThe delivery mode affected the SFQ28 partner domain. Episiotomy affected the arousal (sensation) domain. Multiple regression analysis revealed that maternal age and cesarean section were significantly associated with several SHQ28 domains.Conclusion
This study suggests that routine episiotomies at delivery should be avoided to improve postpartum maternal sexual function. Maternal age and cesarean section were found to affect postpartum sexual health. Song M, Ishii H, Toda M, Tomimatsu T, Katsuyama H, Nakamura T, Nakai Y, and Shimoya K. Association between sexual health and delivery mode. Sex Med **;**:**–**.

Full text

Association Between Sexual Health and Delivery Mode
Mihyon Song, MD,* Hiroshi Ishii, MS,* Masahiro Toda, PhD,†Takuji Tomimatsu, PhD,*
Hironobu Katsuyama, PhD,‡Takafumi Nakamura, PhD,* Yuichiro Nakai, PhD,* and
Koichiro Shimoya, PhD*
*Department of Obstetrics and Gynecology, Kawasaki Medical School, Kurashiki City, Okayama, Japan; †Department of
Public Health, Wakayama Medical University, Wakayama City, Wakayama, Japan; ‡Department of Public Health,
Kawasaki Medical School, Kurashiki City, Okayama, Japan
DOI: 10.1002/sm2.46
ABSTRACT
Introduction. Female sexual function changes considerably during pregnancy and the postpartum period.
In addition, women’s physical and mental health, endocrine secretion, and internal and external genitalia
vary during these times. However, there are limited studies on the relationship between delivery and sexual
function.
Aim. The present study aimed to demonstrate the association between sexual function and delivery mode.
Methods. Mothers who delivered a single baby at term were recruited for the study, and 435 mothers were analyzed.
Main Outcome Measures. The Female Sexual Function Questionnaire (SFQ28) scores and mothers’ backgrounds
were assessed at 6 months after delivery.
Results. The delivery mode affected the SFQ28 partner domain. Episiotomy affected the arousal (sensation) domain.
Multiple regression analysis revealed that maternal age and cesarean section were significantly associated with several
SHQ28 domains.
Conclusion. This study suggests that routine episiotomies at delivery should be avoided to improve postpartum
maternal sexual function. Maternal age and cesarean section were found to affect postpartum sexual health. Song M,
Ishii H, Toda M, Tomimatsu T, Katsuyama H, Nakamura T, Nakai Y, and Shimoya K. Association between
sexual health and delivery mode. Sex Med **;**:**–**.
Key Words. Female Sexual Function Questionnaire (SFQ28); Delivery Mode; Episiotomy
Introduction
Female sexual function changes considerably
during pregnancy and the postpartum period.
During this time, the perineum and pelvic floor
muscles are damaged. During breastfeeding, pro-
lactin secretion, which suppresses libido and stimu-
lates estrogen secretion, is increased. Changes in
female sexual function during pregnancy and the
postpartum period are related to endocrine
changes and anatomical change [1]. In Japan, the
term “sexless” is defined as a frequency of sexual
intercourse of <1 time/month. Sexlessness is con-
sidered a social issue, and pregnancy and delivery
are considered contributory factors [2]. In the lit-
erature, approximately 80–95% of mothers return
to sexual activity within 3 months of delivery [1],
but this has not been proven in Japanese women
[3]. Women’s physical and mental health, endo-
crine secretion, and internal and external genitalia
vary during pregnancy and the postpartum
period.
© 2014 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.
on behalf of International Society for Sexual Medicine.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs
License, which permits use and distribution in any medium, provided the original work is properly cited, the use is
non-commercial and no modifications or adaptations are made.
Sex Med **;**:**–**

Several studies demonstrated the association
between sexual function and delivery mode, episi-
otomy, and laceration [4–6]. Other studies
revealed no association between mode of delivery
and sexual function [7–11]. Yeniel and Petri
reviewed the effect of pregnancy and mode of
delivery on postpartum sexual function. There is
no clear evidence of a relationship between the
mode of delivery and changes in sexual function
[12]. There is controversy over the effect of mode
of delivery episiotomy and perineal laceration on
sexual function. To explore the hypothesis that
sexual function is associated with mode of delivery
and laceration is important, because sexual health
is one of critical parts of maternal health. We
planned the present study in Japanese postpartum
women to investigate the relationship of sexual
function with maternal status, delivery mode, epi-
siotomy, and laceration.
Aim
The present study aimed to demonstrate relation-
ships between sexual function and delivery mode.
We determined sexual function by the Female
Sexual Function Questionnaire (SFQ28), which
consisted of the desire domain, the arousal (sensa-
tion) domain, the arousal (lubrication) domain, the
arousal (cognitive) domain, the orgasm domain,
the pain domain, the enjoyment domain, and the
partner domain. Each factor of SFQ-28 was exam-
ined to improve delivery management and post-
partum maternal health.
Methods
Participants
Mothers who delivered a single baby at term at
Kawasaki University Hospital and related hospi-
tals were recruited for this study during a postnatal
examination >1 month after delivery. Six months
following delivery, questionnaires were sent by
mail to mothers who gave informed consent.
Questionnaire responses were analyzed. The data
were collected from November 2011 to June 2013.
As shown in Figure 1, a total of 674 mothers were
enrolled in the study. Informed consent was
obtained from each patient. A total of 502 mothers
returned questionnaires. Sixty-seven mothers were
excluded because of incomplete answers of ques-
tionnaires. A total of 435 mothers were included in
the study. This study was approved by the Ethical
Committee of Kawasaki Medical School.
Main Outcome Measures
The SFQ28
The SFQ28 is a self-reported measure of female
sexual function and was developed to be multidi-
mensional and patient centered. The SFQ28
addresses all aspects of the sexual response cycle
(desire, arousal, orgasm) as well as pain, which is
consistent with the criteria in the Diagnostic and
Statistical Manual of Mental Disorders and the
newly generated American Foundation for Uro-
logic Disease definitions [13]. We analyzed SFQ
score as sexual function: the primary outcome.
Sociodemographic Items
The self-reported questionnaire included sociode-
mographic and medical items as follows: maternal
age, educational level, occupational status, marital
status, cohabiting status, partner’s occupational
status, obstetric history, and psychiatric history.
Statistical Analysis
Data are reported as mean ±standard deviation.
Statistical significance was assessed using analysis
of variance and the Wilcoxon signed-rank test with
a 5% significance level. The correlation coeffi-
cients between two variables were determined by
Spearman rank analysis. A multiple regression
analysis was undertaken to identify the variables
that predicted sexual health. We performed
forward-backward stepwise selection method for a
multiple regression analysis. The data were ana-
lyzed with IBM SPSS statistics ver. 20 (IBM,
Armonk, NY, USA).
Results
Of the questionnaires that were sent, 435 com-
pletely answered questionnaires were returned.
674 mothers were enrolled in the study.
Quesonnaires were sent by mail.
502 mothers answered the quesonnaires.
435 mothers were analyzed in the study.
172 mothers refused to return the
answers of the quesonnaires.
67 mothers’ answers of the quesonnaires
were incomplete to analyze.
Figure 1 A flowchart of the present study.
2Song et al.
Sex Med **;**:**–** © 2014 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.
on behalf of International Society for Sexual Medicine.

The means of maternal age, age at marriage, infant
birth weight, and gestational weeks at delivery
were 33.2 ±4.4 years, 28.5 ±4.0 years, 3,023 ±
424 g, and 39.2 ±1.4 weeks, respectively. Two
hundred and eighty-two (65%) participants had a
vaginal delivery without oxytocin (Group A), 82
(19%) had a vaginal delivery with oxytocin (Group
B), 21 (5%) delivered by an operative maneuver
such as vacuum and forceps (Group C), 23 (5%)
had preplanned cesarean sections (Group D), and
27 (6%) had emergency cesarean sections (Group
E). There were no significant differences in mater-
nal age, age at marriage, income, academic back-
ground, or cohabitation status among the five
groups. There were significant differences in the
number of children and parity among the five
groups. The mean birth weight and gestational
weeks in the planned cesarean section group were
significantly lower and earlier, respectively. The
scores indicating normal sexual function of the
desire domain, the arousal (sensation) domain,
the arousal (lubrication) domain, the arousal
(cognitive) domain, the orgasm domain, the pain
domain, the enjoyment domain, and the partner
domain are more than 23, 14, 8, 8, 12, 12, 23, and
8, respectively. The numbers of mothers indicat-
ing normal sexual function of the desire domain,
the arousal (sensation) domain, the arousal (lubri-
cation) domain, the arousal (cognitive) domain,
the orgasm domain, the pain domain, the enjoy-
ment domain, and the partner domain were 1
(0.2%), 33 (7.6%), 5 (1.1%), 12 (2.8%), 7 (1.6%),
48 (11.0%), 7 (1.6%), and 362 (83.2%), respec-
tively. The normal sexual function of postpartum
Japanese women at 6 months after birth was very
low.
Table 1 shows the related quotient (rvalue) to
determine relationships among each category.
Maternal age was significantly associated with the
number of children and each SFQ28 domain. The
number of children was significantly associated
with the SFQ28 pain domain. Many SFQ28
domains were significantly associated with each
other.
Female sexual function was analyzed based on
two different classifications. The first classification
was based on the delivery mode, with classifica-
tions separated into a vaginal delivery group,
including delivery with oxytocic agents (Group
A+B), an operative delivery group (Group C),
and a cesarean section group, including both
planned and emergency cesarean sections (Group
D+E). As shown in Figure 2, the score of the
partner domain of Group A +B (vaginal delivery),
Group C (portative delivery), and Group D +E
(cesarean section) were 8.7 ±2.2, 9.3 ±1.2, and
9.1 ±1.5, respectively. There were significant dif-
ferences in the SFQ28 partner domains between
the vaginal and operative delivery groups. There
were also nonsignificant differences in the orgasm
and pain domains. The score in the SFQ28 partner
domain for the cesarean section group was
nonsignificantly higher than that for the vaginal
delivery group.
The second classification was based on the con-
dition of the perineum following delivery, with
classifications separated into a no laceration group,
an episiotomy group, a laceration group (up to a
level three laceration) without episiotomy, and a
cesarean section group. Table 2 presents the scores
for each SFQ28 domain in each group; the
domains include desire, arousal (lubrication),
Table 1 Related quotient (rvalue) among each SFQ28 domain
Maternal
age
Numbers
of children
SFQ28
Desire
Arousal
(sensation)
Arousal
(lubrication)
Arousal
(cognitive) Orgasm Pain Enjoyment Partner
Maternal age 1.000
Numbers of children 0.202* 1.000
Desire −0.137* −0.087 1.000
Arousal (sensation) −0.167* 0.064 0.651* 1.000
Arousal (lubrication) −0.206* 0.061 0.642* 0.924* 1.000
Arousal (cognitive) −0.178* 0.057 0.685* 0.926* 0.940* 1.000
Orgasm −0.105* 0.071 0.597* 0.787* 0.794* 0.801* 1.000
Pain −0.180* 0.139* 0.542* 0.821* 0.848* 0.827* 0.694* 1.000
Enjoyment −0.167* 0.010 0.737* 0.892* 0.903* 0.922* 0.820* 0.819* 1.000
Partner 0.009 0.050 0.045 −0.028 −0.029 0.015 0.021 −0.020 0.036 1.000
*Significant difference (P<0.05) between the two categories
SFQ28 =Female Sexual Function Questionnaire
Delivery and Maternal Sexual Function 3
Sex Med **;**:**–**© 2014 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.
on behalf of International Society for Sexual Medicine.

arousal (cognitive), orgasm, pain, enjoyment, and
partner. The no laceration group was compared
with the other groups. There was a nonsignificant
difference in the SFQ28 arousal (lubrication) and
orgasm domains between the no laceration and
episiotomy groups. There were no statistical dif-
ferences for any of the SFQ28 domains between
the no laceration and cesarean section groups. As
shown in Figure 3, the scores of the arousal (sen-
sation) domain of the no laceration group, the
episiotomy group, the laceration group, and the
cesarean section group were 4.8 ±5.8, 3.5 ±4.7,
4.1 ±5.4, and 3.8 ±5.2, respectively. There was a
significant difference in the arousal (sensation)
domain between the no laceration and episiotomy
groups. The incidence of sexlessness (no inter-
course in 4 weeks) regardless of the husband’s
presence during delivery was found to be 56% and
58%, respectively, with no statistical difference.
Finally, a multiple regression analysis was per-
formed to determine the variables that predicted
sexual health. Maternal age and cesarean section
were significant predictors of the SHQ28 domains
of desire (P=0.005 and P=0.015, respectively),
arousal (lubrication) (P=0.003 and P=0.032,
respectively), and arousal (cognitive) (P=0.007
and P=0.036, respectively). Maternal age was a
significant predictor of the enjoyment domain
(P=0.001). Associations of the SHQ28 orgasm
domain with maternal age was P=0.071. Associa-
tions of the SHQ28 pain domain with maternal
age and cesarean section were P=0.057 and
P=0.071, respectively.
Discussion
The present study is the first to analyze the
association between maternal sexual function and
0
2
4
6
8
10
Group A+B Group C Group D+E
SFQ28 score (partner)
p = 0.076
p < 0.05
Vaginal delivery Operave delivery Cesarean secon
Figure 2 Female Sexual Function Questionnaire (SFQ28)
partner domain score and the delivery mode. Data repre-
sent the mean ±standard deviation. Group A: vaginal deliv-
ery group, Group B: vaginal delivery with oxytocin group,
Group C: operative delivery group, Group D: planned cesar-
ean section group, Group E: emergency cesarean section
group. The SFQ28 partner domain score for the vaginal
delivery group was significantly higher than that of the
operative delivery group.
Table 2 Sexual activity (SFQ28 score) and laceration at delivery
No laceration Episiotomy Laceration
Cesarean
section
Desire 8.2 ±3.6 8.3 ±3.4 8.0 ±3.5 9.1 ±3.9
Arousal (lubrication) 2.7 ±3.1 2.1 ±2.9 2.4 ±3.015 2.2 ±2.9
Arousal (cognitive) 2.5 ±3.0 2.0 ±2.8 2.2 ±2.9 2.1 ±2.8
Orgasm 3.6 ±4.6 2.8 ±4.0 2.8 ±4.2 3.5 ±4.5
Pain 5.1 ±5.6 4.1 ±5.4 4.3 ±5.4 4.0 ±5.2
Enjoyment 8.4 ±7.6 7.6 ±7.3 7.5 ±7.1 7.9 ±7.6
Partner 8.9 ±1.7 8.7 ±2.2 8.7 ±2.4 9.1 ±1.5
Data represent the score of each domain of SFQ as mean ±standard deviation
SFQ28 =Female Sexual Function Questionnaire
0
2
4
6
8
10
No laceraon Episiotomy Laceraon Cesarean
secon
p < 0.05
SFQ28 score
Arousal (sensaon)
Figure 3 Female Sexual Function Questionnaire (SFQ28)
arousal (sensation) domain score and laceration at delivery.
Data represent the mean ±standard deviation. There was a
significant difference in the arousal (sensation) domain
between the no laceration and episiotomy groups.
4Song et al.
Sex Med **;**:**–** © 2014 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.
on behalf of International Society for Sexual Medicine.

maternal status, delivery mode, episiotomy, and
laceration. There were significant differences in
the SFQ28 partner domain between the vaginal
and operative delivery groups. There were also
nonsignificant differences in the orgasm and pain
domains. The association between delivery mode
and postpartum sexual activity is controversial. In a
12-month study of 912 pregnant women and their
husbands, instrumental deliveries were associated
with the highest and planned cesarean section with
the lowest rate of long-term maternal and paternal
sexual dysfunction [5]. Our results were similar to
Safarinejad et al.’s study [5], because of the similar
timing of the examination. One study demon-
strated that both cesarean section and perineal
scars were associated with sexual malfunction [4].
However, another study demonstrated that elec-
tive cesarean delivery was not associated with a
protective effect on postpartum sexual function
[8]. Gungor et al. demonstrated that sexual dissat-
isfaction should not be assumed simply a product
of the delivery mode. Individual, sociodemo-
graphic, lifestyle, and marital characteristics
should also be taken into account [9]. Mode of
delivery history appeared to have minimal effect
on sexual function at 6 years post-index delivery
[7]. Fehniger et al. reported the sexual function of
women aged 40 years and older with at least one
past child event. The sexual activities of women
were not associated with a history of cesarean
delivery compared with vaginal delivery alone.
Women with a history of operative-assisted deliv-
ery were more likely to report low desire [10].
Operative-associated delivery affected sexual func-
tion for a long time. Low partnership in the
operative-assisted delivery in our study might
affect the long-term sexual function. Because the
interval between the delivery time and the study
time differs in the studies, the association between
delivery mode and postpartum sexual activity is
controversial. Accordingly, further investigation is
necessary to determine the relationship between
maternal sexual health and the delivery mode.
In the present study, episiotomy had negative
effects on sexual function in Japan. All SFQ28
domains were superior in mothers without lacera-
tion and episiotomy. However, we could not dem-
onstrate the cause and the effect of episiotomy on
sexual function because of our cross-sectional
single-time point data. This was one of the limi-
tations of the present study. Several studies have
demonstrated a relation between the condition of
the perineum after delivery and sexual function.
Large lacerations (anal sphincter laceration)
damaged the maternal sexual activity [14,15]. In 55
postpartum women compared with women with
intact perineum, those who had both episiotomy
and second-degree perineal tears had lower levels
of libido, orgasm, and sexual satisfaction and more
pain during intercourse at 3 months after delivery
[6]. Another study demonstrated that there was no
significant difference in sexual function 12–18
months after childbirth between women who
delivered vaginally without episiotomy, heavy
perineal laceration, or secondary operative inter-
ventions and women who underwent elective
cesarean section [11]. A meta-analysis revealed
that evidence does not support maternal benefits
traditionally ascribed to routine episiotomies.
Routine episiotomies also have negative effects on
maternal sexual function and activity. For instance,
pain with intercourse was more common among
women who underwent an episiotomy [16]. Our
results also supported the negative effects of
episiotomies on female sexual function. Including
the present study, we recommend that routine epi-
siotomy be avoided at delivery to improve mater-
nal sexual function after delivery.
We examined the incidence of sexlessness (no
intercourse for 4 weeks) regardless of the hus-
band’s presence during delivery. Japanese are sexu-
ally hypoactive, and it is speculated that the
husband’s presence during delivery affects the
postnatal sexual activity of the couple [3].
However, there was no statistical difference in the
incidence of sexlessness regardless of the hus-
band’s presence during delivery. This finding
encourages husband’s attendance to support his
wife during delivery.
Multiple regression analysis revealed that
maternal age and cesarean section were signifi-
cantly associated with several SHQ28 domains.
Maternal age and cesarean section affected post-
partum sexual health. The negative effects of
cesarean sections on maternal sexual health should
be considered. A recent review revealed no clear
evidence relating the delivery mode of delivery to
changes in sexual function [12]. However, the
interval between delivery and the study and the
ethnicity differed from the present study. Another
study demonstrated that both cesarean and
perineal scars were associated with sexual malfunc-
tion [4], and our study supported the previous
study. The strengths of the present study were
sample size and the same ethnical background;
however, the limitation was that the present study
was one-point examination and there was no
predelivery assessment. Thus, further investiga-
Delivery and Maternal Sexual Function 5
Sex Med **;**:**–**© 2014 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.
on behalf of International Society for Sexual Medicine.

tions are necessary to study the association
between sexual health and the delivery mode.
Conclusion
Our study demonstrated that maternal age and
cesarean section were significantly associated with
several SHQ28 domains. Further investigation is
necessary to determine the relationship between
maternal sexual health and the delivery mode. To
improve maternal sexual function after delivery,
we recommend that routine episiotomy be avoided
at delivery to improve postnatal maternal sexual
function.
Acknowledgments
The authors thank Dr. Kaoru Miyake (Miyake Clinic),
Dr. Takeshi Taniguchi (Taniguchi Hospital), and Dr.
Haruyoshi Urano (Ikuryo Clinic) for recruiting the par-
ticipants. This work was supported, in part, by Grants-
in-Aid for Scientific Research (Nos. 21592118,
24592493) from the Ministry of Education, Science,
and Culture of Japan (Tokyo, Japan), Health Labor Sci-
ences Research Grant of Research on Child and Fami-
lies (Tokyo, Japan), and research project grants 21-411,
25B-14, and 25G-6 from Kawasaki Medical School
(Kurashiki, Japan).
Corresponding Author: Koichiro Shimoya, PhD,
Department of Obstetrics and Gynecology, Kawasaki
Medical School, 577 Matsushima, Kurashiki City,
Okayama 701-0192, Japan. Tel: (81) 86-462-1111; Fax:
(81) 86-462-1199; E-mail: shimoya@med.kawasaki-
m.ac.jp
Conflict of Interest: The authors report no conflicts of
interest.
References
1 Johnson CE. Sexual health during pregnancy and the postpar-
tum. J Sex Med 2011;8:1267–84.
2 Abe T. Sexless couples and psychosextherapy.
Sanfujinkachiryou 1994;10:388–93, (in Japanese).
3 Frequency of sexual intercourse and satisfaction. (in
Japanese) 2014. Available at: http://www.durex.com/en
-JP/SexualWellbeingSurvey/Fequency%20of%20Sex/pages/
default.aspx
4 Lal M, Pattison HM, Allan TF, Callender R. Does post-
caesarean dyspareunia reflect sexual malfunction, pelvic floor
and perineal dysfunction? J Obstet Gynaecol 2011;31:617–30.
5 Safarinejad MR, Kolahi AA, Hosseini L. The effect of the
mode of delivery on the quality of life, sexual function, and
sexual satisfaction in primiparous women and their husbands. J
Sex Med 2009;6:1645–67.
6 Rathfisch G, Dikencik BK, Kizilkaya Beji N, Comert N,
Tekirdag AI, Kadioglu A. Effects of perineal trauma on post-
partum sexual function. J Adv Nurs 2010;66:2640–9.
7 Dean N, Wilson D, Herbison P, Glazener C, Aung T,
Macarthur C. Sexual function, delivery mode history, pelvic
floor muscle exercises and incontinence: A cross-sectional
study six years post-partum. AustNZJObstet Gynaecol
2008;48:302–11.
8 Lurie S, Aizenberg M, Sulema V, Boaz M, Kovo M, Golan A,
Sadan O. Sexual function after childbirth by the mode of
delivery: A prospective study. Arch Gynecol Obstet
2013;288:785–92.
9 Gungor S, Baser I, Ceyhan S, Karasahin E, Acikel CH. Mode
of delivery and subsequent long-term sexual function of
primiparous women. Int J Impot Res 2007;19:358–65.
10 Fehniger JE, Brown JS, Creasman JM, Van Den Eeden SK,
Thom DH, Subak LL, Huang AJ. Childbirth and female
sexual function later in life. Obstet Gynecol 2013;122:988–
97.
11 Klein K, Worda C, Leipold H, Gruber C, Husslein P, Wenzl
R. Does the mode of delivery influence sexual function after
childbirth? J Womens Health (Larchmt) 2009;18:1227–31.
12 Yeniel AO, Petri E. Pregnancy, childbirth, and sexual function:
Perceptions and facts. Int Urogynecol J 2014;25:5–14.
13 Quirk FH, Heiman JR, Rosen RC, Laan E, Smith MD, Boolell
M. Development of a sexual function questionnaire for clinical
trials of female sexual dysfunction. J Womens Health Gend
Based Med 2002;11:277–89.
14 Brubaker L, Handa VL, Bradley CS, Connolly A, Moalli P,
Brown MB, Weber A, Pelvic Floor Disorders Network. Sexual
function 6 months after first delivery. Obstet Gynecol
2008;111:1040–4.
15 Ejegård H, Ryding EL, Sjogren B. Sexuality after delivery with
episiotomy: A long-term follow-up. Gynecol Obstet Invest
2008;66:1–7.
16 Hartmann K, Viswanathan M, Palmieri R, Gartlehner G,
Thorp J Jr, Lohr KN. Outcomes of routine episiotomy: A
systematic review [Review]. JAMA 2005;293:2141–8.
6Song et al.
Sex Med **;**:**–** © 2014 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.
on behalf of International Society for Sexual Medicine.