Impact of Mode of Delivery on Female Postpartum Sexual Functioning:

Spontaneous Vaginal Delivery and Operative Vaginal Delivery vs Cesarean

Section
Giussy Barbara, MD,1 Paola Pifarotti, MD,2 Federica Facchin, PhD,3 Ivan Cortinovis, MD,4 Dhohua Dridi, MD,5
Camilla Ronchetti, MD,2 Luca Calzolari, MD,2 and Paolo Vercellini, MD5

ABSTRACT

Introduction: Several studies have explored the association between modes of delivery and postpartum female
sexual functioning, although with inconsistent ndings.
Aim: To investigate the impact of mode of delivery on female postpartum sexual functioning by comparing
spontaneous vaginal delivery, operative vaginal delivery, and cesarean section.
Methods: One hundred thirty-two primiparous women who had a spontaneous vaginal delivery, 45 who had an
operative vaginal delivery, and 92 who underwent a cesarean section were included in the study (N 269).
Postpartum sexual functioning was evaluated 6 months after childbirth using the Female Sexual Function Index.
Time to resumption of sexual intercourse, postpartum depression, and current breastfeeding also were assessed 6
months after delivery.
Main Outcome Measures: Female Sexual Function Index total and domain scores and time to resumption of
sexual intercourse at 6 months after childbirth.
Results: Women who underwent an operative vaginal delivery had poorer scores on arousal, lubrication, orgasm,
and global sexual functioning compared with the cesarean section group and lower orgasm scores compared with
the spontaneous vaginal delivery group (P < .05). The mode of delivery did not signicantly affect time to
resumption of sexual intercourse. Women who were currently breastfeeding had lower lubrication, more pain at
intercourse, and longer time to resumption of sexual activity.
Conclusion: Operative vaginal delivery might be associated with poorer sexual functioning, but no conclusions
can be drawn from this study regarding the impact of pelvic oor trauma (perineal laceration or episiotomy) on
sexual functioning because of the high rate of episiotomies. Overall, obstetric algorithms currently in use should
be rened to decrease further the risk of operative vaginal delivery.
J Sex Med 2016;13:393e401. Copyright
2016, International Society for Sexual Medicine. Published by Elsevier
Inc. All rights reserved.
Key Words: Postpartum Female Sexual Function; Mode of Delivery; Pregnancy; Vaginal Delivery; Cesarean
Section

Received April 13, 2015. Accepted November 22, 2015.

INTRODUCTION

Department of Obstetrics and Gynecology, G. Fornaroli Hospital, via Al

Donatore di sangue 50, Magenta, Milan, Italy;

Several studies have demonstrated that female postpartum

sexual functioning should be considered a complex phenomenon
that can considerably affect female sexuality and the quality of
intimate relationships.1,2 According to the World Health Organization, all women should be asked about resumption of sexual
intercourses and possible dyspareunia, as a part of an assessment
of overall well-being two to six weeks after delivery.3

Copyright 2016, International Society for Sexual Medicine. Published by

Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jsxm.2016.01.004

Womens postpartum sexual functioning can be inuenced by

hormonal variations and by the physical changes in female
genitalia caused by childbirth. Research has shown that women
in postpartum can have problems in the resumption of sexual

Urogynecology Unit, Department of Womens and Childrens Health,

Fondazione IRCCS Ca Granda, Milan, Italy;

Faculty of Psychology, Catholic University of Milan, Milan, Italy;

Unit of Medical Statistics and Biometry, Department of Clinical Sciences

and Community Health, Universit degli Studi, Milan, Italy;

Department of Clinical Sciences and Community Health, Universit degli

Studi di Milano and Gynecology Unit, Department of Womens and
Childrens Health, Fondazione IRCCS Ca Granda, Milan, Italy

J Sex Med 2016;13:393e401

393

394

intercourse, loss of desire, dyspareunia, lack of lubrication, pain,

and decreased orgasmic capacity.1,2,4e7 Loss of desire and dyspareunia should be considered the predominant sexual problems,
with a prevalence ranging from 22% to 86%.1,4
Postpartum hormonal status and breastfeeding can be associated with low desire, arousal and lubrication problems, and
difculties in achieving orgasm.8,9 Postpartum sexual activities
also can be inuenced by psychological factors, such as depression, anxiety, parenting stress and fatigue, and body dissatisfaction.2,8e10 Moreover, experiencing pain during intercourse
can inhibit the sexual response cycle, with negative effects on
multiple dimensions of female sexuality.
Recent studies have shown increasing interest in exploring the
association between womens postpartum sexual function and
mode of delivery, although with inconsistent ndings.7,11e31
Overall, elective cesarean section (CS) and vaginal delivery
with an intact perineum seem to play a protective role for
postpartum female sexuality.7 The available evidence suggests
that cesarean delivery could prevent the development of pelvic
oor relaxation and pudendal neuropathy, whereas vaginal delivery, especially when operative, could have detrimental effects
on desire, arousal, time to resumption of sexual intercourse, pain,
and sexual satisfaction.13,20,28e34 According to the ndings of a
recent British survey, a large proportion of female obstetricians
would choose an elective CS for themselves to avoid the risk of
pelvic oor injuries and future sexual dysfunctions involved by
vaginal delivery.35,36 The increase in elective CSs in Europe and
other countries, such as in Latin America, might be due in part to
this belief.37e39
Other studies have shown inconsistent ndings regarding
elective vs emergency CS or eutocic vs operative vaginal delivery
(OVD).1,4,10e27 Therefore, no rm conclusion can be drawn
about the association between mode of delivery and postpartum
sexual functioning.
These discrepancies might be due to differences in the
methodology adopted, populations examined (eg, nulliparous vs
multiparous women), type of sexual questionnaires administered,
sexual outcomes chosen, follow-up duration, and indications for
mode of delivery. Indeed, some studies have focused only on
short-term sexual outcomes11,25 and others have used nonvalidated questionnaires.1,4,10e12,14,16

AIMS
In the present study, we compared the impact of two types of
vaginal delivery (spontaneous vaginal delivery [SVD] and OVD)
with CS on female postpartum sexual functioning. Our main
hypothesis was that vaginal delivery (spontaneous or operative)
would be associated with worse sexual outcomes and longer time to
resumption of sexual activity compared with CS. These worse
outcomes for the two vaginal delivery groups were expected
because several studies have demonstrated that vaginal delivery
itself can have a detrimental effect on the pelvic oor and can cause

Barbara et al

pudendal neuropathy; these types of damage might be associated

with impaired postpartum sexual functioning.13,20,28e34 The
worst outcomes are expected for OVDwhich in Italy involves
the use of vacuum extractorbecause it can cause more severe
injuries to pelvic oor muscles, nerves, and connective tissue.7,28
Moreover, this study aimed at evaluating the impact of two potential confounders: diagnosis and treatment for postpartum
depression and current breastfeeding.

METHODS
Participants and Procedures
The present study is part of a larger research on the mode of
delivery and pelvic oor dysfunction. The investigation was
conducted during 2013 at the Department of Womens and
Childrens Health, Fondazione IRCCS Ca Granda, Ospedale
Maggiore Policlinico, Milan, Italy. Institutional review board
approval for the study was obtained. Women were consecutively recruited during the rst 3 days after delivery before
discharge from the hospital. At recruitment, trained researchers provided complete information about the aims and
methods of the study and claried all aspects of the research
protocol. Written informed consent was obtained from all
women who agreed to participate in the study.
Women were eligible if they were Caucasian primiparous
women 18 to 45 years old, could understand and speak Italian,
had a body mass index lower than 30 kg/m2, and delivered at 37
weeks of gestation or later. Patients in the CS group were eligible
only if they had an elective CS (owing to breech presentation,
maternal request, medical maternal, or fetal indications) or a CS
during labor but performed at a cervical dilatation less than 3 cm
to avoid the potential confounding effect of labor. Therefore,
women who underwent emergency CSs at a more advanced stage
of cervical dilatation (ie, >3 cm, because of failure of induction
of labor or non-reassuring fetal heart rate patterns) were
excluded. Other exclusion criteria were multifetal gestation,
history of chronic maternal illness (eg, diabetes mellitus and
cardiovascular, neurologic, and renal diseases), and gestational
complications such as preeclampsia, deep vein thrombosis,
placenta previa, or antepartum or postpartum hemorrhages.
At recruitment we collected sociodemographic (age, level of
education, current occupation, and smoking habits during
pregnancy) and anthropometric (height and weight) data; information on female sexual functioning before delivery (ie, in the
third trimester of pregnancy) also was gathered retrospectively.
Six months after delivery, we assessed postpartum sexual functioning, time to resumption of sexual intercourse, diagnosis and
treatment of postpartum depression, and current breastfeeding.
The characteristics of the vaginal deliveries (type of episiotomy,
degree of perineal laceration, use of vacuum extractor, and
duration of the second stage of labor), indications for cesarean
deliveries, and neonatal weight were retrieved from the hospital
medical records.
J Sex Med 2016;13:393e401

Impact of Mode of Delivery on Female Postpartum Sexual Functioning

MAIN OUTCOME MEASURES

The main outcome measurements regarded postpartum sexual
functioning. The Italian version of the Female Sexual Function
Index (FSFI) was used to assess womens sexuality.40e42 The
FSFI is a 19-item validated self-report questionnaire that evaluates womens sexual functioning with a specic focus on six
different sexual domains: desire, arousal, lubrication, orgasm,
satisfaction, and pain. All these sexual dimensions can be negatively affected by vaginal delivery.1,2,4e7 Although a full-scale
score can be calculated, each subscale can be scored and
treated as an independent scale. Domain scores are obtained by
adding the scores of the items that comprise the domain and then
multiplying the sum by a specic domain factor; the transformed
maximum score for each domain is 6, with higher scores indicating better sexual functioning. The FSFI total score (range
2e36) is obtained by adding the six domain scores; lower scores
are associated with a higher degree of sexual dysfunction. A fullscale score no higher than 26.5 indicates the presence of female
sexual dysfunction.41e43
Participants completed the FSFI at recruitment (ie, within the
rst 3 days after delivery) and at 6 months after delivery. At
recruitment, all women were asked to complete the FSFI to
evaluate their sexual functioning retrospectively before delivery,
with a focus on the third trimester of pregnancy. These data were
collected only to determine whether the three study groups were
equivalent at study entry for the main outcome variables and
were not used to address pre- and postpartum comparisons,
which were beyond the scope of this study. Six months after
delivery, participants completed the FSFI a second time to
evaluate current postpartum sexual functioning; moreover,
women were asked to indicate the time to resumption of sexual
intercourse after childbirth. The presence of postpartum
depression and current breastfeeding also were assessed using a
dichotomous variable (ie, yes 1, no 0). For postpartum
depression, participants were asked whether they had been
diagnosed with and were under treatment (ie, antidepressants
and/or psychotherapy) for postpartum depression.

Statistical Analysis
Statistical analyses were conducted using SPSS 15 (SPSS Inc.,
Chicago, IL, USA). Continuous variables are presented as mean
SD and qualitative variables are presented as frequency. Preliminary analyses examined whether the three groups (ie, SVD,
OVD, and CS) differed on all study variables at recruitment
(study entry). One-way and multivariate analyses of variance
were used to detect group differences on continuous variables.
Comparisons between qualitative variables were performed
using the c2 test. When signicant group differences were
found at recruitment, these variables were entered as putative
covariates in the subsequent analyses.
Preliminary analyses also were conducted to assess the relation
between the characteristics of the vaginal deliveries (type of
J Sex Med 2016;13:393e401

395

episiotomy and duration of the second stage of labor) and each

outcome variable for the SVD and OVD groups using Pearson
correlations and multivariate analysis of variance. Then, a set of
multiple hierarchical regressions was conducted to investigate the
impact of the three modes of delivery on the outcome variables
while controlling for the effects of the putative covariates (ie,
differences at study entry, postpartum depression, and current
breastfeeding). The putative covariates were entered in regression
step 1. The independent variable group was transformed in
coded variables using dummy coding.44,45 Our coding system
involved two dummy variables (D1 and D2), with the CS group
chosen as the base group whose mean was compared with the
mean of the SVD group (D1) and with the mean of the OVD
group (D2). Because we wanted to address a third comparison
(ie, SVD vs OVD), we conducted a second set of regressions in
which the two dummy variables compared the mean of the OVD
group (chosen as the base group) with the mean of the SVD
group (D3) and the mean of the CS group (D4). In these two
sets of analyses, the two dummy variables were entered in
regression step 2. Unstandardized regression coefcients (B) of
each coded variable represent the difference between the mean of
the groups of interest and the mean of the base group.

RESULTS
Preliminary Analyses: Characteristics of
Participants at Study Entry
A owchart of the study is presented in Figure 1. Of the 600
women originally recruited, 505 returned consent forms and
completed the measurements. The main reasons for declining
participation were the lack of time to attend the 6-month
appointment and that the study was perceived as intrusive. Of
the original 505 women, 177 (55.3%) who had a vaginal delivery
and 92 (49.7%) who had a CS completed measurements at the
two assessment times, with an overall 53.3% retention rate, and
were included in the statistical analyses. Of the 177 participants
who delivered vaginally, 45 (25.4%) had an OVD. Thus, the
three nal study groups were composed by 132 women who had
an SVD, 45 who had an OVD, and 92 who underwent a CS.
Overall, 236 women did not attend the 6-month appointment.
Most of these women withdrew from the study because they did
not have the time to attend the 6-month postpartum appointment owing to care of the newborn.
The mean age of the 269 nal participants was 34.4 4.9
years. Although the three study groups were equivalent in body
mass index before pregnancy, education, current occupation, and
smoking habits during pregnancy (P > .05 for all comparisons),
signicant differences were found for womens age (P < .001).
No signicant baseline differences were found for the six FSFI
domains and for the total score (P > .05 for all comparisons).
One hundred seven participants (39.8%) reported sexual
dysfunction (ie, FSFI total score  26.5). The characteristics of
participants by study group at study entry are listed in Table 1.

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Barbara et al

Figure 1. Flowchart of study. CS cesarean section; OVD operative vaginal delivery; SVD spontaneous vaginal delivery.
The characteristics of the vaginal deliveries are listed in
Table 2. One hundred fty-one women (85.3%) had an episiotomy, more often with a mediolateral incision rather than with
a median incision. All episiotomies were protective for anal
sphincter lacerations. Twenty-eight women (15.8%) had a
spontaneous perineal laceration and six of them (3.4%) had a
third- or fourth-degree laceration.

Postpartum Sexual Functioning

Postpartum characteristics of participants by study group are
presented in Table 3. Overall, 47 participants (17.5%) had
postpartum depression and 107 (39.8%) were currently breastfeeding their child. The FSFI full-scale scores indicated that 110
participants (40.9%) reported sexual dysfunction.
The relations between the type of episiotomy and the duration
of the second stage of labor and each outcome variable (FSFI six
domains, FSFI full-scale score, and time to resumption of intercourse) were preliminarily assessed. Findings showed no signicant association (P > .05 for all comparisons).
The multiple hierarchical regressions showed that the OVD
group had poorer postpartum sexual functioning compared with
the CS group for arousal (B 0.471, standard error [SE]
0.192, P .015, 95% CI 0.849 to 0.093, DR2 0.024),
lubrication (B 0.451, SE 0.226, P .047, 95%

CI 0.897 to 0.005, DR2 0.014), orgasm (B 0.627,

SE 0.253, P .014, 95% CI 1.125 to 0.129, DR2
0.028), and FSFI full-scale score (B 2.566, SE 0.995, P
.010, 95% CI 4.525 to 0.607, DR2 0.024). Compared
with the OVD group, the SVD group had higher scores for
orgasm (B 0.605, SE 0.233, P .010, 95% CI
0.145e1.064, DR2 0.028). No signicant differences were
found between the SVD and CS groups. The mode of delivery
did not affect the time to resumption of sexual intercourse (P >
.05 for all comparisons).
Breastfeeding had a signicant impact on lubrication
(B 0.487, SE 0.151, P .001, 95% CI 0.784
to 0.189), pain (B 0.334, SE 0.161, P .039, 95%
CI 0.652 to 0.016), and time to resumption of sexual intercourse (B 0.270, SE 0.136, P .049, 95% CI
0.001e0.539). These ndings showed that women who were
currently breastfeeding had lower lubrication, more pain, and longer
time to resumption of sexual activity. The other putative covariates
(age and postpartum depression) did not have any signicant effect.

DISCUSSION
Several studies have shown the increasing importance of
female postpartum sexual functioning as a complex phenomenon
that might considerably affect womens life.1,2 For this reason, a
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Impact of Mode of Delivery on Female Postpartum Sexual Functioning

Table 1. Participant Variables at Recruitment By Study Group

Study group
Variable

SVD (n 132)

Sociodemographic
Age (y), mean SD
32.4 4.9
Level of education, n (%)
University
77 (58.3)
High school
52 (39.4)
Middle school
3 (2.3)
Current occupation, n (%)
No job
22 (16.7)
Permanent job
85 (64.4)
Temporary job
25 (18.9)
Smoked during pregnancy, yes, n (%)
16 (12.1)
Anthropometric
BMI before pregnancy, mean SD
21.2 2.9
FSFI score before delivery (retrospectively evaluated), mean SD
Desire
3.7 1.2
Arousal
3.9 1.2
Lubrication
4.6 1.9
Orgasm
3.9 1.5
Satisfaction
4.8 1.1
Pain
5.3 0.9
Total
26.3 5.3
Sexual dysfunction, n (%)
50 (37.9)

OVD (n 45)

CS (n 92)

P value*

32.2 4.4

35.5 4.4

<0.001
.095

28 (62.2)
13 (28.9)
4 (8.9)

64 (69.6)
24 (26.1)
4 (4.3)

2 (4.4)
32 (71.1)
22 (24.4)
4 (8.9)

13 (14.1)
63 (68.5)
16 (17.4)
10 (10.9)

.833

21.6 3.9

21.2 2.5

.77

3.7 1.2
4.1 1.1
4.6 1.1
3.9 1.4
4.9 0.9
5.3 1.3
26.4 4.7
19 (42.2)

3.6 1.3
3.8 1.3
4.5 1.3
4.1 1.6
4.8 1.1
5 1.2
25.9 5.6
38 (41.3)

.81
.785
.949
.671
.819
.063
.827
.819

.316

BMI body mass index; CS cesarean section; FSFI Female Sexual Function Index; OVD operative vaginal delivery; SVD spontaneous vaginal delivery.
*P values refer to preliminary analyses.
By analysis of variance.
By c2 test.
By multivariate analysis of variance.

growing amount of research has been focusing on the impact of the

different modes of delivery on postpartum sexual functioning,
although with inconsistent ndings.11e31 Overall, CS seems to be
Table 2. Characteristics of Vaginal Deliveries
Variable
Episiotomy, n (%)
None
26 (14.7)
Mediolateral
126 (71.2)
Median
25 (14.1)
Spontaneous perineal laceration, n (%)
None
149 (84.2)
First degree
10 (5.6)
Second degree
12 (6.8)
Third degree
3 (1.7)
Fourth degree
3 (1.7)
Use of vacuum extractor, n (%)
Yes
45 (25.4)
Duration (min) of second stage of labor, mean SD
SVD
35.4 20.6
OVD
40.5 20.9
OVD operative vaginal delivery; SVD spontaneous vaginal delivery.
J Sex Med 2016;13:393e401

associated with better sexual functioning,13,20,28e33 but more

research is necessary to support this hypothesis.
The present study aimed at investigating whether vaginal delivery and CS yielded different effects on two sexual outcomes:
postpartum female sexual functioning, measured with a validated
questionnaire (ie, the FSFI), and the time to resumption of
sexual intercourse. All study groups (SVD, OVD, and CS) had a
rather large percentage of participants reporting sexual dysfunction during the third trimester of pregnancy, with no signicant
between-group differences.
This nding is not surprising because several studies have
associated late pregnancy with impaired female sexuality, especially with regard to desire, arousal, and orgasm.46,47 However,
because we did not assess womens sexual functioning before
pregnancy, we cannot make any causal inference on the relation
between pregnancy and low sexual functioning in the sample
studied. Information on sexual functioning during the third
trimester of pregnancy was collected retrospectively at recruitment (within the rst 3 days after delivery). Therefore, several
factorssuch as hospitalization, hormonal and emotional
adaptation to motherhood, and the physical impact of
deliverymight limit the accuracy of these self-reported data.

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Barbara et al

Table 3. Participant Variables at 6 Months After Delivery by Study

Group
Study group

Variable
Postpartum
depression,
yes, n (%)
Current breastfeeding,
yes, n (%)
FSFI score, mean SD
Desire
Arousal
Lubrication
Orgasm
Satisfaction
Pain
Total
Sexual dysfunction,
n (%)
Time (mo) to
resumption of
sexual intercourse,
mean SD

SVD
(n 132)

OVD
(n 45)

CS
(n 92)

25 (18.9)

9 (20)

13 (14.1)

56 (42.4)

17 (37.8)

34 (37)

3.8 1.1
4.3 1.0
4.3 1.2
4.6 1.3
4.8 1.0
4.9 1.3
26.9 5.2
56 (42.4)

3.6 1.2
4.1 1.1
4.1 1.4
4.0 1.5
4.7 1.1
4.7 1.3
25.3 5.9
23 (51.1)

3.9 1.1
4.6 1.0
4.5 1.1
4.7 1.3
5.0 1.1
4.9 1.3
27.7 5.2
31 (33.7)

2.3 1.1

2.5 1.2

2.2 1.0

CS cesarean section; FSFI Female Sexual Function Index; OVD

operative vaginal delivery; SVD spontaneous vaginal delivery.

Postpartum sexual functioning was assessed at 6 months after

childbirth and we cannot exclude that sexual problems observed
at 6 months might no longer exist after 1 year. Moreover, we
found a small difference between the FSFI total scores retrospectively assessed for the third trimester of pregnancy and those
observed at 6 months postpartum.
In this study, the FSFI scores referred to the third trimester of
pregnancy and were used only to compare the three groups at
study entry and to exclude the presence of between-group differences before delivery. The cross-sectional nature of this study
should be considered a methodologic limitation; the most
appropriate way to address our research question would be a
prospective study comparing female sexual functioning at the
beginning of pregnancy (study entry), at 6 months after delivery
(medium-term effects of delivery), and at 1 year after delivery
(long-term effects of delivery). This indication should be
considered a suggestion for future research on the impact of
mode of delivery on female sexual functioning.
Our main ndings associated OVD with worse postpartum
sexual functioning compared with CS (lower arousal, lubrication,
orgasm, and global sexual functioning) and with SVD (lower
orgasm). On the one hand, these results are consistent with those
provided by other studies. Negative effects of operative obstetric
interventions have been reported in a recent large multicenter
prospective cohort study on the relation among mode of delivery,
perineal trauma, and dyspareunia.7 Signorello et al28 reported

that in women who had vaginal delivery, perineal trauma and use
of obstetric instrumentation were associated with the frequency
or severity of postpartum dyspareunia, suggesting that the extent
of perineal trauma during delivery should be minimized.
On the other hand, our ndings are in contrast with those of
other investigators.13,19,22,26,27,34 For instance, Lurie et al27
found that postpartum female sexual functioning (assessed 6,
12, and 24 weeks after childbirth) was not affected by the mode
of delivery (ie, vaginal without or with episiotomy, instrumental
vaginal delivery, and elective or emergency CS). Baytur et al13
did not observe differences in FSFI scores between vaginal delivery and cesarean delivery or correlations between pelvic oor
muscle strength and arousal, desire, lubrication, orgasm, pain,
and satisfaction. Barrett et al34 found that the protective effects of
CS on postpartum sexual functioning were limited to the rst 3
months after delivery and primarily related to pain symptoms. In
a recent prospective cohort study, Faisal-Cury et al48 investigated
the relation between mode of deliveryuncomplicated vaginal
delivery (SVD without episiotomy or any kind of perineal
laceration), complicated vaginal delivery (with forceps or normal,
with episiotomy or any kind of perineal laceration), and CS and
sexual health outcomes after childbirth (ie, resumption of sexual
life, self-perception of decline of sexual life, and presence of
sexual desire) in 831 women. No associations were found between mode of delivery and postpartum sexual outcomes up to
18 months after delivery.
Another contribution of our study concerns the impact of current
breastfeeding on postpartum sexual functioning. Specically, we
found that current breastfeeding was associated with lower lubrication, more pain, and longer time to resumption of sexual intercourse.
These ndings, which conrm those provided in other studies,8,9
suggest that the role of hormonal status associated to breastfeeding
should be taken into account when considering postpartum female
sexuality in research and in counseling.
Our ndings should be interpreted cautiously for several reasons. As shown by the unstandardized regression coefcients (B)
and by the DR2 values, the group differences were small and
therefore might not be clinically meaningful. Moreover, no signicant between-group differences were found in time to
resumption of sexual intercourse, which has been considered by
several investigators as an important sexual dimension that might
be negatively affected by vaginal delivery.19,20,23,27
A major limitation of this study is represented by the proportion of women who underwent episiotomy in our cohort,
which is one of the largest reported in the literature. Graham
et al49 observed that episiotomy rates, including primiparas and
multiparas, range around the world from 9.7% to 100%,
whereas rates for solely primiparas range from 63.3% to 100%.
In general, episiotomy rates tend to be lowest in Englishspeaking countries and in Northern Europe.49 The episiotomy
rate reported in the present study reects the usual practice of our
obstetric school and tends to be stable over time in our hospital.
We cannot exclude that women who had a vaginal delivery
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Impact of Mode of Delivery on Female Postpartum Sexual Functioning

would have performed better had they not undergone episiotomy. However, we conducted preliminary analyses to assess
the association between type of episiotomy and postpartum
sexual functioning, with no signicant ndings. Because only six
women had third- and fourth-degree perineal lacerations, we did
not control for the effects of perineal lacerations on postpartum
sexual functioning, although several studies have associated
perineal lacerations with dyspareunia.7
The percentage of operative vaginal deliveries (25.4%) also
might seem fairly high, although this value is in line with the
proportion of operative deliveries observed in one of the largest
study on this topic.7 In their cohort study, McDonald et al7
reported that among women who delivered vaginally, 10.8%
gave birth assisted by vacuum extraction and 10.7% by forceps.
From a functional and anatomic perspective, postpartum
delayed resumption of sexual intercourse and dyspareunia
might be caused by episiotomy or perineal trauma owing to an
operative or difcult vaginal delivery.5e7 Vascular nerve injuries
and extreme stretching and/or compression of nerve bers
caused by vaginal delivery can have a detrimental impact on the
neural pathways implicated in arousal and orgasm. The pudendal nerve is responsible for sexual pleasure and orgasm and,
if damaged by delivery, can cause impaired arousal, lubrication,
and orgasm, which can lead to decreased sexual satisfaction.
Therefore, sexuality might be globally impaired by vaginal delivery, especially when operative. Our ndings do not allow us
to draw any conclusion about the impact of labor on the pelvic
oor, because only women who underwent an elective CS
before labor or at cervical dilatation less than 3 cm were
included in the study. Moreover, although OVD was associated
with poorer sexual functioning compared with the other two
modes of delivery, our study does not provide any evidence
regarding the presence and severity of pudendal nerve injuries
occurring during labor and/or delivery, because pudendal nerve
function was not evaluated.
Although the sample size of the present study was not originally calculated to consider the main outcome of the present
investigation, a post hoc analysis showed that the study population was large enough to detect a between-group difference of
2.5 points in the FSFI total score at the usual levels of a (a
0.05) and b (80%). This should be considered a small difference
and we believe that a type II error regarding clinically important
differences in sexual function can be reliably ruled out. However,
our participants might not be fully representative of the overall
postpartum female population: we had a high attrition rate, with
a nal relatively small sample composed by Caucasian women.
Future research should be conducted on a larger sample of
women and should control for the effects of cross-cultural
differences on postpartum sexual outcomes. Future studies
also should investigate the impact of subjective factors, such as
womens thoughts and feelings experienced during delivery. For
instance, an OVD could represent a traumatic event in a
womans life; this type of experience might be associated with
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399

intrusive memories and negative emotions that could negatively

affect womens postpartum sexual functioning. Couple-related
variables, such as partners satisfaction and attitudes or dyadic
coping strategies, also should be controlled because they might
affect postpartum sexual functioning of the couple. Moreover,
future research on this topic should be conducted prospectively,
starting before or at the beginning of pregnancy and with a
long-term follow-up after delivery, comparing well-dened
different groups with respect to the mode of delivery (vaginal
birth without episiotomy, vaginal birth with episiotomy,
vaginal birth with an intact perineum, OVD, primary CS,
secondary CS).
Because of the methodologic limitations discussed earlier, the
present study cannot state that women who underwent a CS had
better postpartum sexual functioning. However, our data support
the existence of a relation between mode of delivery and womens
medium-term postpartum sexual functioning, suggesting that
OVD might have a negative impact on postpartum female
sexuality. Therefore, obstetric algorithms currently in use should
be rened with the objective of further decreasing the risk of
OVD. This would imply a benecial effect not only on the
overall safety of delivery, quality of womens psychological
experience, and risk of urogynecologic repercussions but also on
womens postpartum sexual functioning.
Corresponding Author: Giussy Barbara, MD, Department of
Obstetrics and Gynecology, G. Fornaroli Hospital, via Al
Donatore di sangue 50, Magenta, Milan 20122, Italy; E-mail:
giussy.barbara@gmail.com
Conict of Interest: The authors report no conicts of interest.
Funding: None.

STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Giussy Barbara; Paola Pifarotti; Paolo Vercellini
(b) Acquisition of Data
Giussy Barbara; Dhohua Dridi; Camilla Ronchetti; Luca Calzolari
(c) Analysis and Interpretation of Data
Giussy Barbara; Federica Facchin; Ivan Cortinovis; Paolo
Vercellini
Category 2
(a) Drafting the Article
Giussy Barbara; Federica Facchin; Paolo Vercellini
(b) Revising It for Intellectual Content
Paola Pifarotti; Ivan Cortinovis; Dhohua Dridi; Camilla Ronchetti;
Luca Calzolari
Category 3
(a) Final Approval of the Completed Article
Giussy Barbara; Paola Pifarotti; Federica Facchin; Ivan
Cortinovis; Dhohua Dridi; Camilla Ronchetti; Luca Calzolari;
Paolo Vercellini

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