Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women.

OBJECTIVE: Our goal was to evaluate the relationship between obstetric perineal trauma and postpartum sexual functioning. STUDY DESIGN: Our study was carried out with a retrospective cohort design in 3 groups of primiparous women after vaginal birth: Group 1 (n = 211) had an intact perineum or first-degree perineal tear; group 2 (n = 336) had second-degree perineal trauma; group 3 (n = 68) had third- or fourth-degree perineal trauma. These sample sizes reflect a 70% response rate. Outcomes were time to resuming sexual intercourse, dyspareunia, sexual satisfaction, sexual sensation, and likelihood of achieving orgasm. RESULTS: At 6 months post partum about one quarter of all primiparous women reported lessened sexual sensation, worsened sexual satisfaction, and less ability to achieve orgasm, as compared with these parameters before they gave birth. At 3 and 6 months post partum 41% and 22%, respectively, reported dyspareunia. Relative to women with an intact perineum, women with second-degree perineal trauma were 80% more likely (95% confidence interval, 1.2--2.8) and those with third- or fourth-degree perineal trauma were 270% more likely (95% confidence interval, 1.7--7.7) to report dyspareunia at 3 months post partum. At 6 months post partum, the use of vacuum extraction or forceps was significantly associated with dyspareunia (odds ratio, 2.5; 95% confidence interval, 1.3--4.8), and women who breast-fed were > or = 4 times as likely to report dyspareunia as those who did not breast-feed (odds ratio, 4.4; 95% confidence interval, 2.7--7.0). Episiotomy conferred the same profile of sexual outcomes as did spontaneous perineal lacerations. CONCLUSIONS: Women whose infants were delivered over an intact perineum reported the best outcomes overall, whereas perineal trauma and the use of obstetric instrumentation were factors related to the frequency or severity of postpartum dyspareunia, indicating that it is important to minimize the extent of perineal damage incurred during childbirth.

Midline episiotomy and anal incontinence: retrospective cohort study.

OBJECTIVE: To evaluate the relation between midline episiotomy and postpartum anal incontinence. DESIGN: Retrospective cohort study with three study arms and six months of follow up. SETTING: University teaching hospital. PARTICIPANTS: Primiparous women who vaginally delivered a live full term, singleton baby between 1 August 1996 and 8 February 1997: 209 who received an episiotomy; 206 who did not receive an episiotomy but experienced a second, third, or fourth degree spontaneous perineal laceration; and 211 who experienced either no laceration or a first degree perineal laceration. MAIN OUTCOME MEASURES: Self reported faecal and flatus incontinence at three and six months postpartum. RESULTS: Women who had episiotomies had a higher risk of faecal incontinence at three (odds ratio 5.5, 95% confidence interval 1.8 to 16.2) and six (3.7, 0.9 to 15.6) months postpartum compared with women with an intact perineum. Compared with women with a spontaneous laceration, episiotomy tripled the risk of faecal incontinence at three months (95% confidence interval 1.3 to 7.9) and six months (0.7 to 11.2) postpartum, and doubled the risk of flatus incontinence at three months (1.3 to 3.4) and six months (1.2 to 3.7) postpartum. A non-extending episiotomy (that is, second degree surgical incision) tripled the risk of faecal incontinence (1.1 to 9.0) and nearly doubled the risk of flatus incontinence (1.0 to 3.0) at three months postpartum compared with women who had a second degree spontaneous tear. The effect of episiotomy was independent of maternal age, infant birth weight, duration of second stage of labour, use of obstetric instrumentation during delivery, and complications of labour. CONCLUSIONS: Midline episiotomy is not effective in protecting the perineum and sphincters during childbirth and may impair anal continence.