Pain With Sexual Intercourse Linked to Mode of Delivery

Laurie Barclay, MD

January 21, 2015

Obstetric intervention is linked to persistent postpartum dyspareunia, or pain during or after sexual intercourse, according to a prospective cohort study published January 21 in BJOG. Clinicians should also be aware that intimate partner abuse is another risk factor for postpartum dyspareunia.

"Almost all women experience some pain during first sexual intercourse following childbirth," lead author Ellie McDonald, PhD, from the Murdoch Children's Research Institute, Melbourne, Victoria, Australia, said in a news release.

"However, our findings show the extent to which women report persisting dyspareunia at 6 and 18 months postpartum is influenced by events during labour and birth, in particular caesarean section and vacuum extraction delivery."

At six maternity hospitals in Melbourne, Australia, the investigators recruited 1507 nulliparous women in the first and second trimesters of pregnancy. Of these, 1244 participants (83%) completed questionnaires at baseline and at 3, 6, 12, and 18 months postpartum.

Nearly half (49.0%) had spontaneous vaginal delivery, with two thirds of these having a sutured tear and/or episiotomy. Nearly one fifth of participants had emergency caesarean section, 10.8% had operative vaginal birth assisted by vacuum extraction, 10.7% had forceps-assisted delivery, and 9.7% had elective caesarean section.

By 18 months postpartum, 97.7% had resumed vaginal intercourse, and 23.4% reported dyspareunia, which was the main outcome measure.

Univariable and multivariable logistic regression showed that operative intervention was linked to dyspareunia at 18 months, after adjustment for maternal age and other potential confounders. Adjusted odds ratio for this outcome was 2.41 (95% confidence interval [CI], 1.4 - 4.0; P = .001) for emergency caesarean section vs spontaneous vaginal delivery with intact perineum or unsutured tear.

The adjusted odds ratio was also increased for vacuum extraction (2.28; 95% CI, 1.3 - 4.1; P = .005) and for elective caesarean section (1.71; 95% CI, 0.9 - 3.2; P = .087) compared with spontaneous delivery.

"Not enough is known about the longer term impact of obstetric procedures on maternal health," Dr McDonald said in the news release. "The fact that dyspareunia is more common among women experiencing operative procedures points to the need for focusing clinical attention on ways to help women experiencing ongoing morbidity, and increased efforts to prevent postpartum morbidity where possible."

Other factors associated with dyspareunia at 18 months postpartum were dyspareunia before pregnancy (odds ratio [OR], 2.09; 95% CI, 1.5 - 2.8; P = .000), intimate partner abuse in the first 12 months postpartum (OR, 1.84; 95% CI, 1.3 - 2.6; P = .001), and maternal fatigue (OR, 1.51; 95% CI, 1.1 - 2.1; P = .018). In the first 12 months postpartum, 16% of participants reported abuse by an intimate partner, and 32.4% of these reported dyspareunia at 18 months postpartum compared with 20.7% of women who did not report such abuse.

"This is the first study with detailed, frequent and long-term follow-up to assess associations of dyspareunia with obstetric risk factors," Patrick Chien, BJOG deputy editor-in-chief said in a news release.

"This study provides us with robust evidence about the extent and persistence of postpartum dyspareunia and associations with mode of delivery and perineal trauma. Future research could look into ways of preventing dyspareunia."

Limitations of this study include reliance on self-report, sample limited to first-time deliveries, and underrepresentation of younger women and non-English-speaking women born overseas.

This research was supported by project grants from the Australian National Health and Medical Research Council, a VicHealth Public Health Research Fellowship, a National Health and Medical Research Council Career Development Fellowship, an ARC Future Fellowship, a La Trobe University Postgraduate Scholarship, and the Victorian Government’s Operational Infrastructure Support Programme. The authors have disclosed no relevant financial relationships.

BJOG. Published online January 21, 2015.

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