Interpretation
Under the assumption that the association of perineal trauma plays a causative role in the later occurrence of sexual dysfunction and dyspareunia, it would seem that perineal trauma needs to be avoided whenever possible. Obviously, this factor is not always that easily malleable, except for the trauma that is iatrogenic in nature: based on our observations, liberal use of episiotomy in non-instrumental deliveries, as a strategy to reduce sexual dysfunction, should not be recommended. Also, perineal trauma is more likely following instrumental vaginal delivery, therefore – if clinically feasible- women should be offered the opportunity to discuss the risks and benefits of instrumental delivery with their physician.
We found that cesarean section is not protective neither for sexual dysfunction, nor for dyspareunia occurring within the first year after delivery, when compared to spontaneous delivery. We did not anticipate this, as cesarean section typically makes perineal trauma very unlikely, hence should be protective. Apparently other factors than perineal trauma, may play a more important role in the development of pelvic floor sexual dysfunction. Also, the included studies may have measured dysfunction rather late after delivery (Median months after delivery [IQR]: 6.0 [5.1; 7.5]), by what time any difference according to delivery mode, may have faded out(32-35). Also, women who are at high risk for sexual dysfunction, may be more likely to receive a cesarean section, because of that dysfunction – though the data we have do not allow us to make that conclusion.
It is difficult to make a firm statement on the different impact of elective or emergency cesarean section, as only three studies were included that report outcomes after elective and emergency section separately. Prado et al. who reported on sexual dysfunction at 6-8 months after delivery, did not find any difference between elective cesarean section and vaginal delivery (RR:1.23[0.87-1.74]; p=0.26), whereas emergency cesarean section was increasing the odds for sexual dysfunction (RR:1.68[1.14-2.48])(28). O’Malley et al. and Lipschuetz et al. reported on dyspareunia at 12 months after delivery(26, 27); we pooled their count data in the supplement (Figure S4). Apparently, elective cesarean section was protective for dyspareunia (OR:0.50[0.29-0.85]), though no difference was found between emergency cesarean section and vaginal delivery (OR:0.91[0.61-1.35]). Moreover, the effect of mode of delivery on sexual function, might be limited in time, and though this study looked a pre-existing dyspareunia, it did not report separately on de novo sexual dysfunction(26). In conclusion, our observations do not suggest the existence of obvious upfront risk factors for sexual dysfunction in relation to delivery mode, whereas perineal trauma is. This may however be a risk factor that is not easily modifiable. The occurrence of perineal trauma should alert the clinician for the later likelihood for sexual dysfunction, which should be brought up during postpartum surveillance and may benefit from active management(36).