FeaturesPostpartum sexual functioning and method of delivery: Summary of the evidence
Introduction
Each year approximately 4 million women give birth in the United States. In 2001, nearly 25% of live births were by cesarean delivery and 6.3% by assisted vaginal delivery via forceps or vacuum extraction. Subsequent serious maternal morbidity is responsible for substantial disruption of early parenting, increased family burden, and health care costs among women of childbearing age.1 Postpartum sexual functioning is a type of morbidity about which little has been studied, yet the impact of type of delivery on subsequent sexual health remains uncertain and few modifiable risk factors have been identified.
Although very little has been published about the mode of birth and postpartum sexual functioning, popular media report that women are concerned about potential negative effects of childbirth on their sexual health. Current topics in Oprah, Redbook, and Parents Magazine identify childbirth as a factor in sexual functioning and discuss questions, such as “why sex is painful after childbirth” and “does cesarean delivery improves one’s sex life.”2, 3, 4 Such media reports reflect beliefs that women who have cesarean delivery rather than a vaginal birth may have better subsequent sexual functioning.
Women’s concerns about sexual functioning after childbirth are not unfounded. Short-term postpartum sexual changes, including dyspareunia and loss of desire, are highly prevalent among women, with rates ranging from 22% to 86%.5, 6, 7 Despite reports of unusually high rates of sexual problems following childbirth, the relationship between the type of delivery and sexual problems remains largely inconclusive. Previous studies examined the possibility that the mechanical trauma associated with assisted vaginal delivery may be an important determinant of sexual activity following childbirth. Researchers have reported a significant increase in perineal pain at 8 weeks postpartum,8 greater occult sphincter defects at 6 weeks postpartum,9 and more pain in intercourse at 1 year postpartum10 among women with assisted vaginal delivery relative to a spontaneous vaginal delivery. This finding suggests that assisted delivery may impair sexual functioning.
Since the late 1990s, some health care professionals and consumers have advocated for cesarean on demand to protect pelvic floor integrity. For example, a Brazilian study reported that doctors believe women prefer cesarean delivery because it allows them to avoid the pain of vaginal delivery, they recover their figures more quickly, and they do not jeopardize future sexual functioning.11 Yet the consequences of type of delivery on sexual health specifically are not well established. To inform the discussion, we critically reviewed evidence on selected postpartum sexual function outcomes as affected by cesarean, assisted vaginal, and spontaneous vaginal delivery to identify strengths, weaknesses, and gaps in peer-reviewed published research.
Section snippets
Methods
We focused our literature search on the most commonly reported sexual health outcomes, which included perineal pain, dyspareunia, timing of resumption of intercourse, and self-reported perception of sexual health. We searched PubMed, CINAHL, and Cochrane databases from January 1990 through September 2003 using the terms postpartum sexual functioning cesarean, postpartum sexual functioning vaginal birth, postpartum sexual health vaginal delivery, postpartum sexual health vaginal birth, sexual
Results
The search resulted in review of 38 abstracts, of which 16 were relevant. Of the possibly 16 relevant articles, six were eligible for inclusion. Three of the studies presented only psychosocial aspects of sexual dysfunction,12, 13, 14 five articles did not separate assisted from spontaneous vaginal delivery,15, 16, 17, 18, 19 one study did not address sexual function outcomes,20 and one study was the pilot study to an included research article.21 Table 1 summarizes the six eligible studies and
Conclusions
Our review of the evidence suggests a strong association between assisted vaginal delivery and some degree of sexual dysfunction.5, 7, 8, 22, 23, 24 All studies that assessed perineal pain reported that the greatest risk for increased perineal pain occurred among women with assisted vaginal delivery.5, 8, 22 However, reported associations between cesarean delivery and perineal pain, dyspareunia, and delay in resumption of sexual intercourse postpartum were inconsistent.5, 8, 23, 24 Two studies
Clinical implications
Within these six studies, women with spontaneous vaginal deliveries had fewer postpartum problems in regard to their sexual functioning than women with assisted vaginal deliveries. Comparing forceps to vacuum deliveries, there is a lower incidence of overall maternal morbidity with vacuum (OR, 0.41; 95% CI, 0.33–0.51).57 When assisted vaginal delivery is necessary, providers could choose interventions that may minimize the mechanical trauma to the perineum: considering vacuum instead of
Future research
Given the potential negative impact of sexual health problems on women’s quality of life following childbirth, the frequency of operative intervention at birth, and the desire of many women for more information about sexual health following childbirth, research is surprisingly scant.58 This line of inquiry is worthy of further consideration among a longitudinal cohort of women using instruments with established psychometric properties, because the interventions and events accompanying and
Tara L. Hicks, BSN, RN, CCRN, is an infectious disease nurse practitioner graduate student in the Department of Biobehavioral Nursing and Systems Management, School of Nursing, University of Washington, Seattle, Washington.
References (61)
Sexuality during pregnancy and after childbirthA metacontent analysis of 59 studies
J Psychosom Res
(1999)- et al.
Health after childbirthA comparison of normal and assisted vaginal delivery
Midwifery
(1993) Are Brazilian women really choosing to deliver by cesarean?
Soc Sci Med
(2000)- et al.
Health consequences of pregnancy and childbirth as perceived by women and clinicians
Obstet Gynecol
(1998) - et al.
Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation
Am J Obstet Gynecol
(1994) - et al.
Infections complicating low-risk cesarean sections in community hospitalsEfficacy of antimicrobial prophylaxis
Am J Obstet Gynecol
(1990) - et al.
Anal sphincter trauma during instrumental delivery
Int J Gynaecol Obstet
(1993) - et al.
Long-term effects of cesarean sectionsEctopic pregnancies and placental problems
Am J Obstet Gynecol
(1996) - et al.
First birth cesarean delivery and placental abruption or previa at second birth
Obstet Gynecol
(2001) - et al.
Epidural analgesia and third- or fourth-degree lacerations in nulliparas
Obstet Gynecol
(1999)
Severe perineal lacerations during vaginal deliveryThe University of Miami experience
Am J Obstet Gynecol
Is there a benefit to episiotomy at operative vaginal delivery? Observations over ten years in a stable population
Am J Obstet Gynecol
Sequential use of instruments at operative vaginal deliveryIs it safe?
Am J Obstet Gynecol
The effect of sequential use of vacuum and forceps for assisted vaginal delivery on neonatal and maternal outcomes
Am J Obstet Gynecol
Cesarean section as a cause of chronic pelvic pain
Int J Gynaecol Obstet
National Vital Statistics Reports. US Department of Health and Human Services [Internet]
Christina Ferrare on women’s unspoken secret [Internet]
All about c-sectionsA troubling trend [Internet]
Why is sex still painful after childbirth? [Internet]
Prevalence and persistence of health problems after childbirthAssociations with parity and method of birth
Birth
Women’s sexual health after childbirth
Br J Obstet Gynaecol
Sexual function after childbirthWomen’s experiences, persistent morbidity and lack of professional recognition
Br J Obstet Gynaecol
Anal-sphincter disruption during vaginal delivery
N Engl J Med
Sex and relationships following childbirthA first report from general practice of 131 couples
Br J Gen Pract
Women’s health after childbirthA longitudinal study in France and Italy
Br J Obstet Gynaecol
Postpartum dyspareunia. An unexplored problem
J Reprod Med
Recovery after childbirthA preliminary prospective study
Med J Aust
Changes in women’s physical health during the first postpartum year
Arch Fam Med
Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at termThe international randomized term breech trial
JAMA
Birth traumaShort and long term effects of forceps delivery compared with spontaneous delivery on various pelvic floor parameters
Br J Obstet Gynaecol
Cited by (73)
Sexuality in the perinatal period: A systematic review of reviews and recommendations for practice
2021, Sexual and Reproductive HealthcareCitation Excerpt :At the same time, other evidence suggests that Caesarean section can negatively impact sexual function due to the development of maternal morbidity and complications following abdominal surgery. Likewise, even if the trauma to the pelvic floor appears to be reduced in women who have given birth by Caesarean section prior to 8 cm dilation, chronic pelvic pain is increased compared to women who have given birth vaginally [20]. There are conflicting results regarding the impact of breastfeeding on sexuality.
Health related quality of life of women at the sixth week and sixth month postpartum by mode of birth
2017, Women and BirthCitation Excerpt :At six months postpartum, significantly more women in the forceps group reported being less satisfied with sexual relations than before pregnancy than in the emergency caesarean group. Several studies have reported that decreased sexual satisfaction and sexual dysfunction may occur after any type of birth, although these are more frequent after instrumental births.48,60,61 This problem, which can cause considerable distress to women, is frequently ignored, despite being a common postpartum disorder.
Impact of Mode of Delivery on Female Postpartum Sexual Functioning: Spontaneous Vaginal Delivery and Operative Vaginal Delivery vs Cesarean Section
2016, Journal of Sexual MedicineCitation Excerpt :Several studies have shown the increasing importance of female postpartum sexual functioning as a complex phenomenon that might considerably affect women’s life.1,2 For this reason, a growing amount of research has been focusing on the impact of the different modes of delivery on postpartum sexual functioning, although with inconsistent findings.11–31 Overall, CS seems to be associated with better sexual functioning,13,20,28–33 but more research is necessary to support this hypothesis.
Postpartum Care and Long-Term Health Considerations
2016, Obstetrics: Normal and Problem PregnanciesThe Relationship Between Mode of Delivery and Sexual Health Outcomes after Childbirth
2015, Journal of Sexual Medicine
Tara L. Hicks, BSN, RN, CCRN, is an infectious disease nurse practitioner graduate student in the Department of Biobehavioral Nursing and Systems Management, School of Nursing, University of Washington, Seattle, Washington.
Susan Forester Goodall, CNM, and Evelyn M. Quattrone, CNM, are 2003 graduates of the Nurse-Midwifery program in the Department of Family and Child Nursing, School of Nursing, University of Washington, Seattle, Washington.
Mona T. Lydon-Rochelle, CNM, MPH, PhD, is an Assistant Professor in the Department of Family and Child Nursing, School of Nursing, University of Washington, Seattle, Washington.