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).