The effect of mode of delivery on postpartum sexual fuctioning in primiparous women

Abstract

The objective of this paper is to evaluate the effect of mode of delivery on postpartum sexual functioning in primiparous women. A total of 248 primiparous women were recruited into this study. One hundred fifty-six delivered spontaneously with mediolateral episiotomy and 92 had elective cesarean section. Sexual function was evaluated by the Female Sexual Function Index, a validated questionnaire separately evaluating desire, lubrication, orgasm, satisfaction, and pain. Subjects were questioned relating their pre-pregnancy experiences during the first antenatal visit when the pregnancy was not more than six gestational weeks. The test was repeated 6 months postpartum. Statistical evaluation was carried out by SPSS for Windows v.11. In the vaginal delivery with mediolateral episiotomy group, there were significant decreases in the scores 6 months after delivery when compared to scores before pregnancy (p<0.001). In the cesarean section group, no difference was observed between pre-pregnancy and postpartum scores (p>0.05). When the two groups were compared, there was a significant difference between 6 months postpartum scores (p<0.001). Not only pain, but also other important aspects of sexual function, such as arousal, lubrication, orgasm, and satisfaction are affected by performing mediolateral episiotomy during vaginal delivery, well beyond the puerperal period. Concerning its effects on postpartum sexual functioning, a policy of restricting mediolateral episiotomy use should be adopted.

Full text

ORIGINAL ARTICLE
The effect of mode of delivery on postpartum sexual
functioning in primiparous women
Basak Baksu & Inci Davas & Eser Agar & Atıf Akyol &
Ahmet Varolan
Received: 14 December 2005 / Accepted: 14 May 2006
#
International Urogynecology Journal 2006
Abstract The objective of this paper is to evaluate the
effect of mode of delivery on postpartum sexual function-
ing in primiparous women. A total of 248 primiparous
women were recruited into this study. One hundred fifty-six
delivered spontaneously with mediolateral episiotomy and
92 had elective cesarean section. Sexual function was
evaluated by the Female Sexual Function Index, a validated
questionnaire separately evaluating desire, lubrication,
orgasm, satisfaction, and pain. Subjects were questioned
relating their pre-pregnancy experiences during the first
antenatal visit when the pregnancy was not more than six
gestational weeks. The test was repeated 6 months postpar-
tum. Statistical evaluation was carried out by SPSS for
Windows v.11. In the vaginal delivery with mediolateral
episiotomy group, there were significant decreases in the
scores 6 months after delivery when compared to scores
before pregnancy (p<0.001). In the cesarean section group,
no difference was observed between pre-pregnancy and
postpartum scores (p>0.05). When the two groups were
compared, there was a significant difference between
6 months postpartum scores (p<0.001). Not only pain, but
also other important aspects of sexual function, such as
arousal, lubrication, orgasm, and satisfaction are affected by
performing mediolateral episiotomy during vaginal deliv-
ery, well beyond the puerperal pe riod. Concerning its
effects on postpartum sexual functioning, a policy of
restricting mediolateral episiotomy use should be adopted.
Keywords Pregnancy
.
Vaginal delivery
.
Episiotomy
.
Cesarean delivery
.
Sexual functioning
Introduction
Even though postpartum mental and physical problems of
women are evaluated thoroughly, studies about the sexual
health after delivery are very few [1–6]. Since most of the
attention is paid to the infan t, even in industrialized
countries, mother’s health and needs are ignored [5].
The small number of studies about postpartum sexual
health have had various limitations, mostly with the
methodology like the sample size, including multiparous
women, failing to discriminate between women with vaginal
delivery and cesarean section, comparing groups with mixed
degrees of perin eal trauma, using volunteers for the survey,
or the method by which sexual health was evaluated [7, 8].
However, reports from developed countries point out some
common problems encountered after birth like dyspareunia,
decrease in libido and, therefore, in the frequency of sexual
intercourse [3–5, 9]. Association between dyspareunia and
perineal damage, especially due to episiotomy, is reported
in many studies [3–5, 9]. Such evidence raises the question
about elective cesarean section as women’s choice for
delivery, comprising 4–18% of all cesarean sections in
reported series, even though professional organizations do
not agree on the ethics of offering it [10–12].
In a country like Turkey where traditions are very
important, talking about sexuality is still a taboo even after
marriage. Therefore, it seems that while Turkish women are
able to discu ss contraception with a health professional,
Int Urogynecol J
DOI 10.1007/s00192-006-0156-0
B. Baksu
:
I. Davas
:
E. Agar
:
A. Akyol
:
A. Varolan
2nd Gynecology and Obstetrics Clinic,
Sisli Etfal Training and Research Hospital,
Istanbul, Turkey
Present address:
B. Baksu ( *)
Nato Yolu Cad. Doktorlar Sitesi A9 Blok D:9,
Cengelkoy, Istanbul, Turkey
e-mail: basakbaksu@yahoo.com

only a small proportion ask for medi cal care about their
sexual health problems during the postpartum period.
Moreover, there are few reports that investigate how the
mode of delivery affects postpartum sexual functioning
[13]. We came across only one report investigating the
postpartum sexual function among Turkish women [14].
Our study tries to focus on the relationship between method
of delivery to various aspects of postpartum sexual function
in a larger number of women from Turkey, which is still a
developing country.
Materials and method
In this prospective study, we used the Female Sexual
Function Index (FSFI) developed by Rosen et al. [15]. The
FSFI is a brief, multidimensional, self-reported, 19-item
validated questionnaire used for the assessment of key
dimensions of sexual function (desire, arousal, lubrication,
orgasm, satisfaction, and pain) in women. We chose this
test because it was proposed to be psychometrically sound,
applicable to all forms of female sexual dysfunction
regardless of etiology, easy to perform, and able to
discriminate between clinical and nonclinical populations.
The FSFI provides scores on six domains using factor
analysis. Each domain is scored on a scale of 0–6, with
higher scores indicating better function. To obtain domain
scores, the scores of individual items comprised in the
domain were added, and the sum was multiplied by the
domain factor. The six domain scores were also added to
obtain the full-scale score, as previously described [15].
The domai n scoring of the FSFI is given in Table 1.A
domain score of zero indicated that the women reported no
sexual function during the last month and the full score
ranged from 2 to 36.
Primiparous women who applied to our antenatal clinic
between January and July 2004 and who gave birth in our
clinic were recruited into the study. Informed consent was
taken before the study, which was approved by the ethical
committee of our hospital. We selected primiparous women
because the postpartum experiences of multiparous women
may be related to previous births. Subjects were asked to
answer the questions relating their pre-pregnancy experi-
ences during the first antenatal visit when the pregnancy
was not more than six gestational weeks. Information about
each woman (e.g., demographic characteristics, medical
history, and obstetric details) was recorded.
All vaginal deliveries were carried out by mediolateral
episiotomy, which is the most commonly performed tech-
nique in our country. The episiotomy repairs were performed
using continuous locking suturing method to the vaginal
tissue, interrupte d stitching to the perineal muscle and
subcutaneous tissue, and interrupted transc utaneous suturing
to the skin. This technique is widely practiced in Turkey.
Continuous method is reported to cause less pain at 10 days
postpartum and reduced overall expenditure compared to
interrupted repair [16]. Chromic catgut was used for all
layers of perineal repair because it is cheap and there is no
need to remove it due to p erineal irritation and tightness
because it is absorbable. Local wound care began immedi-
ately postdelivery. Patients were advised to keep the
perineum clean and dry. After each defecation and voiding,
subjects were instructed to clean the perineum by applying
Batticon. After delivery, women were divided into two
groups: vaginal delivery with mediolateral episiotomy and
elective cesarean section (C/S). Elective cesarean section
indications were transverse lie, fetal weight more than
4,500 g, primiparous breech presentation, advanced mater-
nal age (>35 years), postdate pregnancy (>42 weeks),
oligohydroamnios, and pregnancy due to assisted repro-
ductive technology. Women with extension of episiotomy,
perineal tears or in utero mort. Fetuses and women who had
assisted vaginal delivery or cesarean section after labor
began, preterm births (<37 gesta tional weeks), multiple
pregnancies, birth weight more than 4,000 g, infants with
malformations, women with any syst emic disease (e.g.,
preeclampsia, diabetes mellitus) were excluded. Weight of
the newborns delivered by elective cesarean section was
ignored.
Six months after delivery, women were asked to come
for a control. Then, they were questioned about their infants
(e.g., birth weight, gestational age, any problem the infant
had after birth) and about breast-feeding. The FSFI was
repeated. A 6-mon th period w as chosen because we
Table 1 Domain scoring of female sexual function index
Domain Item number Score range Factor Minimum score Maximum score
Desire 1, 2 1–5 0.6 2 10
Arousal 3, 4, 5, 6 0–5 0.3 0 20
Lubrication 7, 8, 9, 10 0–5 0.3 0 20
Orgasm 11, 12, 13 0–5 0.4 0 15
Satisfaction 14, 15, 16 0 (or1)–5
a
0.4 2 15
Pain 17, 18, 19 0–5 0.4 0 15
a
Range for item 14 is 0–5; range for items 15 and 16 is 1–5
Int Urogynecol J

expected that many women would resume sexual inter-
course by this time, would still be only breast-feeding as
breast-feeding is very common in Turkey, and because of
administrative convenience.
A total of 308 wom en were enrolled in the study and 248
completed the trial. Sixty wom en were excluded from the
study: 21 pregnant women were lost to follow-up during
the postpartum period, 15 had spontaneous abortion of the
current pregnancy, 6 had subsequent health problems or
death of their infants, 8 discontinued breast-feeding, 5
refused to participate, 3 did not answer because they had no
sexual contact till then, and 2 died some months after the
birth. The final sample included 248 women with surviving
infants who were breast-fed; 156 women belong to the
episiotomy group and 92 to the cesarean section group.
Statistical evaluation was carried out by SPSS for
Windows v.11. Independent samples of t test for equality
of means were used for comparison between grou ps.
Logistic regression analysis was used to investigate the
effect of each domain on the total FSFI score.
Results
The descriptive characteristics of the groups are shown in
Table 2. There was no difference between the groups with
regard to age, educat ion level, marital status, employment,
and socioeconomic level.
Elective cesarean section indications are presented in
Table 3.
The FSFI scores of both groups and the comparison
between the groups are given in Table 4.
The comparison between preconceptional and postpar-
tum 6-month scores for the episiotomy group is shown in
Fig. 1. Significant decreases in the test scores were
observed for all the key dimensions of sexual function
(desire, arousa l, lubrication, orgasm, satisfaction) ques-
tioned. The questions regarding pain also showed signifi-
cantly decreased scores.
For the cesarean section group, comparison between
preconceptional and postpartum 6-month scores is shown in
Fig. 2. No significant differences were observed for all the
parameters evaluated.
Even though there was no difference between the two
groups with respect to preconceptional scores, significant
differences were observed between the postpartum scores in
the two groups as shown in Fig. 3.
Logistic regression analysis of domains influencing the
6 months postpartum scores in the mediolateral episiotomy
group were pain (OR, 1.8 5; 95% CI, 0.56 to 4.45),
satisfaction (OR, 1.24; 95% CI, 0.44 to 3.21), lubrication
(OR, 0.82; 95% CI, 0.26 to 2.32), orgasm (OR, 0.76; 95%
CI, 0.18 to 2.34), desire (OR, 0.72; 95% CI, 0.12 to 2.08),
and arousal (OR, 0.64; 95% CI, 0.10 to 1.96).
Discussion
Although sensitive issues like postpartum sexual relations
may actually be of central interest to the woman and her
partner, very little is projected by the couple as health
problems. In a study evaluating the sexual behavior of
women who just gave birth, it was shown that, although
many women reported problems with intercourse, only 7 to
13% expressed the need for help or advise [5]. Moreo ver,
giving information regarding what the couple should expect
or what they might do when they have problems with
sexual life during the postpartum period seems to be
neglected when setting priorities for the health service.
Table 2 Demographic characteristics
Episiotomy (n=156) C/S (n=92)
Age
15–19 0 (0%) 5 (5.43%)
20–24 32 (20.51%) 18 (19.56%)
25–29 102 (65.38 %) 54 (58.69%)
30–34 22 (14.10 %) 15 (16.30%)
≥35 0 (0%) 0 (0%)
Education
Illiterate 7 (4.48%) 4 (4.34%)
Primary school 13 (8.33%) 4 (4.34%)
Middle and high school 76 (48.71%) 42 (45.65%)
University 60 (38.46%) 42 (45.65%)
Marital status
Married 153 (98%) 90 (97.82%)
Divorced 0 0
Single 3 (1.92%) 2 (2.17%)
Socioeconomic status
Low 32 (20.51%) 19 (20.65%)
Middle 80 (51.28%) 45 (48.91%)
High 44 (28.20%) 28 (30.43%)
Employment
Yes 76 (48.71%) 45 (48.91%)
No 80 (51.28%) 47 (51.08%)
Table 3 Elective cesarean section indications
Indication N=92 Percentage (%)
Primiparous breech presentation 25 27.17
Oligohydramnios 22 23.91
Pregnancy due to assisted
reproductive technology
15 16.30
Postdate pregnancy 10 10.86
Fetal weight >4,500 g. 9 9.78
Transverse lie 6 6.52
Advanced maternal age 5 5.43
Int Urogynecol J

The consistent results of studies on mother’s health after
birth have shown that the frequency of various health
problems is high, many of which persist long after the
postpartum period [1, 5 ]. Most researches have shown that
about 90% of postpartum women have resumed sexual
intercourse by 3 to 4 months after birth [9, 17]. Moreover,
in a study evaluating psychological factors and sexuality of
postpartum women, it was reported that at 6 months
postpartum, the quality of the mother role strongly related
to measures of sexuality [18]. Therefore, we considered
evaluating women 6 months after birth because we
expected that many women would have sexual intercourse
by this time. Findings about the hormonal effects associated
with breast-feeding are not consistent across all studies
[19]. Breast-feeding appears to be associated with vaginal
dryness and/or loss of libido [4, 5]. Since all of our subjects
were still breast-feeding, such concerns are not applicable
to our study population.
There is little consensus about whether an episiotomy
specifically predisposes to sexual dysfunction. In a longi-
tudinal prospective study, delivery mode and episiotomy
were reportedly not associated with anorgasmia in primip-
arous women [20]. Signorello et al. [8] found no difference
in reports of dyspareunia between women with perineal
tearing (second and third degree) and women who had
midline episiotomy. Klein et al. [9] reported that there was
no evidence to suggest routine use of episiotomy to prevent
perineal trauma. However, in other studies, an association
between episiotomy and perineal problems like dyspareu-
nia, perineal pain, sexual and pelvic floor morbidity has
been described [3, 4, 9, 21, 22]. In a 3-year follow-up study,
even though women had different types of episiotomy, 14%
reported dyspareunia regardless of the trial intervention [5].
Glazener [5] suggested that problems with sexual inter-
course were strongly associated with perineal pain. He
proposed avoiding perineal damage to reduce problems
experienced with sexual intercourse. In a systematic review
evaluating the outcomes of routine episiotomy, no evidence
was found to support that episiotomy reduced impaired
sexual function; in fact, pain with intercourse was found to
be more common among women with episiotomy [23].
This study was designed to compare postpartum sexual
Table 4 The FSFI scores
Domain Episiotomy group Cesarean section group Postpartum
Pre-pregnancy 6 months postpartum p
a
Pre-pregnancy 6 months postpartum p
b
p
c
Desire 4.87±0.69 4.5±0.55 0.024 4.87±0.69 4.5±0.95 0.084 >0.05
Arousal 4.53±0.93 3.75±0.86 0.001 4.59±0.87 4.83±0.64 0.253 0.0001
Lubrication 5.22±0.56 4.2±0.3 0.000 5.22±0.56 5.04±0.67 0.242 0.0001
Orgasm 5.21±0.58 3.36±0.37 0.000 5.26±0.61 5.48±0.48 0.140 0.0001
Satisfaction 5.22±0.68 4.92±0.31 0.031 5.24±0.69 5.5±0.52 0.100 0.0001
Pain 4.88±0.69 3.12±0.32 0.000 4.93±0.69 4.8±0.7 0.465 0.0001
Total score 28.0±6.92 22.16±3.68 0.000 28.19±6.42 28.32±6.53 0.820 0.0001
a
Comparison between pre-pregnancy and 6 months postpartum scores in the episiotomy group
b
Comparison between pre-pregnancy and 6 months postpartum scores in the cesarean delivery group
c
Comparison of 6 months postpartum scores between groups
Fig. 1 Distribution of FSFI scores in the episiotomy group
Fig. 2 Distribution of FSFI scores in the cesarean section C/S group
Int Urogynecol J

function outcomes within this well-de fined group of
primiparous women with mediolateral episi otomy and with
elective cesarean section. Therefore, it is beyond the scope
of this investigation to determine how women’s answers
regarding sexual functioning would compa re wi th those of
other groups of pregnant women. Moreover, this study
might not be representative at the national level. The
strengths of this study are that it is longitudinal and the
response rate is high. Also, since this study was carried out
at a teaching hospital where the indications for cesarean
section are strictly defined, our results strongly point out
the real difference between the effect of mediolateral
episiotomy and cesarean delivery on sexual function. The
time determined for evaluating postpartum sexual function
was very precise. Also, since the FSFI used for this study is
a multidimensional and self-reported questionnaire applica-
ble to all forms of female sexual dysfunction regardless of
etiology, we believe that respondents were not shy in
answering the questions. This gives a more exact assess-
ment of sexual health of new mothers than retrospective
inquiries.
Our study showed that primiparous women delivered
vaginally by mediolateral ep isiotomy experienced de-
creased levels of desire, arousal, lubrication, orgasm,
satisfaction, and increased level of pain at 6 months
postpartum compared to the elective cesarean section
group. The difference between pre-pregnancy and postpar-
tum scores in the mediolateral episiotomy group seemed to
be mostly due to pain and satisfaction domains of the test.
Klein et al. [9] found that primiparous women with
cesarean section had the strongest pelvic floor at 3 months
postpartum when compared to women with spontaneous
tears or with episiotomy. Vaginal birth was most strongly
associated with pelvic floor relaxation and that episiotomy
was un able to reduce this effect and seemed to have made it
worse. In another study, Klein et al. [6] showed that
women’s sexual dissatisfaction was greater among primip-
arous women who had a vaginal birth when compared to
cesarean section group. Likewise, our results also show a
positive effect of cesarean section on postpartum sexual
functioning when compared to mediolateral episiotomy.
Dyspareunia is reported as one of the reasons why women
might prefer elective cesarean secti on [10, 17]. Klein [6]
found similar frequency of dyspareunia at 3 months
postpartum in primiparous women both in the vaginal birth
and in the cesarean section groups. However, we found
significantly increased pain during intercourse 6 months
after giving birth in the mediolateral episiotomy group,
whereas no difference in pre-pregnancy and 6 months
postpartum scores existed in the cesarean section group.
Moreover, pain, along with satisfaction, seemed to have the
strongest effect on the total FSFI scores. However, reported
associations between cesarean delivery and sexual dysfunc-
tion are inconsistent [13 ]. No effect of mode of delivery on
sexual function was found between women who delivered
vaginally and who underwent cesarean delivery [14].
Hannah et al. [24], in a randomized study of vaginal
delivery vs elective cesarean section for singleton fetus in
breech presentation, found no difference in sexual out-
comes at 3 months and 2 years postpartum outcomes.
Our results provide new data on postpartum sexual
health in women. Even though pain and satisfaction
domains had the most important effect on the total scores,
it was interesting to find out that women in the mediolateral
episiotomy group experienced decreased level of desire
6 months after giving birth when compared to pre-
pregnancy. Probably, they had fear because of the fact that
their perineum was damaged. This fear might also explain
why women with episiotomy had lower level of arousal.
Furthermore, episiotomy may cause problems with lubrica-
tion, which may lead to dissatisfaction and anorgasmia.
Postpartum emotional and physical problems are com-
mon and they tend to increase in time. Complaints like
urinary and fecal incontinence can be improved medically.
However, most emotional health problems seem to go
unrecognized. It is highly probable that sexual disharmony
is a major contributor to the unhappy state of the woman
and her partner. This may lower the quality of life, making
women more anxious and depressed instead of being a
happy and well-coping new mother. Considering the
frequency of sexual health problems, postpartum sexual
morbidity can not simply be assumed to be just a product of
the depressed mental state [25]. In fact, mode of delivery
seems to be a crucial issue in postpartum sexual function-
ing. Therefore, more attention should be paid to the needs
of new mothers, well beyond the puerperal period.
Fig. 3 Comparison of distribution of FSFI scores
Int Urogynecol J

Concerning its effects on postpartum sexual functioni ng,
we should adopt a policy of restricting mediolateral
episiotomy use. Our study gi ves especially important
results in counseling women during the antenatal period
about the way of delivery and related problems in terms of
sexual function outcome. We believe postpartum sexual
counseling should be a part of antenatal follow-up.
Therefore, greater awareness among health care profession-
als of potential sexual problems and the reasons underlying
these difficulties is expected to reduce morbidity and raise
the postpartum quality of life.
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