Difficulty in Resuming Sexual Intercourse After Episiotomy in Primigravida Patients

INTRODUCTION:

Among the most commonly performed obstetric interventions during a vaginal delivery is episiotomy, especially in primigravida women. It entails a surgical cut at the perineum to expand the vaginal aperture to give birth to the child. In the past, episiotomy was a common procedure to avoid serious perineal tears, lessen the fetal harm, and speed up the delivery. Nevertheless, recent evidence indicates that frequent usage is not necessarily healthy and is linked to a number of both short- and long-term complications [1,2]. Difficulty in resuming sexual intercourse is one of the most important postpartum issues that are frequently underreported in clinics. This is of special concern to primigravida patients, who do not have experience of childbirth before and might be more anxious about postpartum recovery. Dyspareunia, which is painful intercourse, is a frequent complaint in the postpartum period following episiotomy and may last a few months. Dyspareunia is a multifactorial problem; it may be caused by the presence of perineal pain, the development of scar tissue, insufficient healing, infection, and muscle dysfunction of the pelvic floor [3,4]. Sexual dysfunction is also a result of hormonal changes in the postpartum period. Lower estrogen levels, particularly in breastfeeding women, result in vaginal dryness and a loss of elasticity, making sex even more uncomfortable. Besides the physical reasons, other psychological aspects of fear of pain, anxiety, distorted body image, and support of partners are important in postponing the time of getting back to sex [5]. Another significant factor that determines postpartum sexual functioning is the kind of episiotomy cut. Even though mediolateral episiotomy is linked to a reduced risk of severe perineal tears, it is commonly associated with more pain and slower recovery than a midline episiotomy. Moreover, inappropriate suture styles, infection, and poor hygiene of the perineum may be additional causes of prolonged pain and delayed healing [6,7]. Although the clinical relevance of sexual health in the postpartum period is hard to overlook, it is a poorly studied field in maternal care, particularly in developing countries where cultural constraints tend to curtail open discourse. There is inadequate counseling for many women on postpartum sexual activity, and this has resulted in misconceptions as well as the development of unnecessary fear. Such ignorance may hurt marital relationships and the quality of life [8,9].It is necessary to understand the prevalence and causes of discomfort in resuming sexual intercourse following episiotomy to enhance postpartum care. Poor wound healing, inadequate pain management, and insufficient education are some of the modifiable risk factors that can be identified to aid the development of targeted interventions. Early counselling, appropriate perineal care, rehabilitation of the pelvic floor, and psychological assistance can go a long way to recovery and achieve better sexual health results [10]. This study will serve the purpose of assessing the incidence and predictors of challenge in reporting sexual intercourse in primigravida women after episiotomy and thus fit into the better maternal health practice and patient-centered care.

Study Objectives

To identify the commonality and correlates of challenge in returning to sex following episiotomy among primigravida and assess clinical results in determining postpartum sexual capabilities.

MATERIALS AND METHOD:

Study Design & Setting

The study was a cross-sectional study conducted in the Department of Obstetrics and Gynecology, Lady Reading Hospital MTI Peshawar, from January 2023 to June 2023 (6 months), and involved postpartum follow-up of primigravida women who underwent episiotomy.

Participants

One hundred primigravida women aged 18-35 years who delivered via vaginal delivery using episiotomy were selected. Recruitment of the participants took place in postpartum visits 6 weeks following delivery. Only women who had uncomplicated singleton pregnancies were recruited, and informed consent was secured before they could join the study.

Sample Size Calculation

A prevalence of 50% was used to determine the sample size of 100 patients with a 95% confidence interval and 10% margin of error. This was a large enough sample that would have sufficient statistical power to identify important associations between variables.

Inclusion Criteria

• Primigravida women

• Age between 18–35 years

• Vaginal birth with episiotomy.

• 6 weeks postpartum period.

• Willingness to participate

Exclusion Criteria

• Multiparous women

• Cesarean delivery

• Severe obstetric complications

• Pre-existing sexual dysfunction

• Chronic medical or mental disease.

Diagnostic Strategy and Management Strategy

The patients were assessed using history, physical examination, and episiotomy healing. A pain scale was used to measure dyspareunia. Management involved counseling, advice on perineal care, use of lubricants, and referral to pelvic floor therapy where warranted.

Statistical Analysis

SPSS version 25 was used to analyze the data. Mean standard deviation was used to express quantitative variables, whereas frequencies and percentages were used to express qualitative variables. Chi-square test was used to determine the relationship between variables, and a p-value of 0.05 and below was regarded as significant.

Ethical Approval Statement

Ethical approval for this study was obtained from the Institutional Review Board/Ethics Committee of Lady Reading Hospital MTI Peshawar prior to commencement of the research. Written informed consent was obtained from all participants, and the study was conducted in accordance with the ethical principles of the Declaration of Helsinki

RESULTS:

Out of 100 primigravida women included in the study, 64% reported difficulty in resuming sexual intercourse after episiotomy. The mean age of participants was 24.8 ± 3.6 years. Dyspareunia was the most common complaint and was reported in 45% of women. Delayed resumption of intercourse beyond 8 weeks postpartum was observed in 61% of participants. Mediolateral episiotomy was associated with a higher frequency of pain (72%) compared to midline episiotomy (48%), with a statistically significant association (p=0.02). Poor wound healing was observed in 18% of cases and was significantly associated with persistent discomfort (p=0.01). Vaginal dryness was reported in 42% of breastfeeding mothers and contributed to painful intercourse. Pelvic floor tenderness was identified in 36% of participants on clinical examination. Only 28% of women had received prior counseling regarding postpartum sexual health. These findings suggest that both physical and psychological factors significantly contribute to delayed resumption of sexual activity after episiotomy.

Intervention Outcome

Sixty percent of the women who received counseling, perineal care instructions, and used lubricants indicated that their symptoms improved after four weeks. Patients who experienced pelvic floor exercises had better results. Education and supportive measures at an early age helped to decrease dyspareunia and the decrease in confidence in resuming sex.

Table 1: Baseline Demographic and Clinical Characteristics (n = 100)

Variable	Value
Age (years, Mean ± SD)	24.8 ± 3.6
Age Range (years)	18–35
Primigravida (%)	100 (100%)
Breastfeeding Mothers (%)	68 (68%)
Mediolateral Episiotomy (%)	58 (58%)
Midline Episiotomy (%)	42 (42%)
Received Counseling (%)	28 (28%)

Table 1 shows the baseline demographic and clinical characteristics of primigravida women included in the study. The mean age was 24.8 ± 3.6 years, and the majority underwent mediolateral episiotomy. Most participants did not receive prior counseling regarding postpartum sexual health.

Table 2: Frequency of Postpartum Sexual Difficulties (n = 100)

Variable	Frequency (%)
Difficulty Resuming Intercourse	64 (64%)
Dyspareunia	45 (45 % )
Delayed Resumption (>8 weeks)	61 (61%)
Fear/Anxiety Related to Pain	36 (36%)
Vaginal Dryness (Breastfeeding Women)	29 (42%)
Pelvic Floor Tenderness	36 (36%)

Difficulty in resuming sexual intercourse was reported in 64% of women, while delayed resumption beyond 8 weeks was observed in 61% of participants. Dyspareunia was present in 45% of the total study population.

Table 3: Association of Episiotomy Type with Pain (n = 100)

Episiotomy Type	Pain Present (%)	Pain Absent (%)	p-value
Mediolateral (n=58)	42 (72%)	16 (28%)	0.02
Midline (n=42)	20 (48%)	22 (52%)

Table 3 demonstrates the association between episiotomy type and pain during intercourse. Mediolateral episiotomy was significantly associated with higher pain compared to midline episiotomy (p=0.02), indicating a potential risk factor for dyspareunia.

Table 4: Factors Associated with Persistent Dyspareunia (n = 100)

Variable	Present (%)	Absent (%)	p-value
Poor Wound Healing	18 (18%)	82 (82%)	0.01
Vaginal Dryness	42 (42%)	58 (58%)	0.03
Lack of Counseling	72 (72%)	28 (28%)	0.02
Pelvic Floor Tenderness	36 (36%)	64 (64%)	0.04

Table 4 presents factors associated with persistent dyspareunia. Poor wound healing, vaginal dryness, lack of counseling, and pelvic floor tenderness were significantly associated with ongoing sexual difficulties, highlighting the multifactorial nature of postpartum dyspareunia

DISCUSSION :

The current study has shown that 64% of primigravida women had a problem with sexual intercourse after episiotomy, and dyspareunia was the most frequent complaint [11]. These results are in line with the recent literature, which defines postpartum dyspareunia as a common yet poorly reported complication. According to recent cross-sectional studies, postpartum dyspareunia remains a common complication after episiotomy. Approximately 27.5% of women experienced dyspareunia 6 weeks after delivery, although most cases were mild to moderate in severity. dyspareunia 6 weeks after delivery, but the majority of dyspareunia was mild to moderate, implying that it may vary depending on population and when it was measured [12]. Recent reviews and systematic reviews have shown that the incidence of dyspareunia following vaginal delivery is between 13 and 60 percent in the initial year of the postpartum period, especially in women who receive an episiotomy [13]. This prevalence could be explained by the fact that we included early cases (6 weeks) after childbirth, during which the symptoms are more severe. Moreover, a meta-analysis indicated a general prevalence of dyspareunia at around 32% after vaginal births, reaffirming the idea that postpartum sexual dysfunction is a major issue in the world [14]. We also found that there was a significant relationship between mediolateral episiotomy and more pain (p=0.02). This has also been found in recent reports, where episiotomy and especially when extensive was strongly linked to increased rates of long-term perineal pain and delayed sexual recovery. Nevertheless, there is some recent study that indicates that restrictive and selective episiotomy could potentially not contribute substantially to the risk of dyspareunia, a fact that is indicative of ongoing controversy on the role of episiotomy in postpartum sexual health [15,16]. Persistent dyspareunia was closely related to poor wound healing and infection (18%) in the present study (p=0.01). This is in line with the results of a large cohort study published in 2024, which indicated that women with postpartum infection or wound complications were three times more likely to have severe dyspareunia one year after childbirth [16]. These findings highlight the significance of adequate perineal care and prompt detection of complications to enhance the outcome [17,18]. Vaginal dryness, mentioned by 42% of the women who had breastfed in our study, also led to painful intercourse. Hormonal hypoestrogenism in lactation is one of the long-known factors that influence vaginal lubrication and vaginal elasticity. Recent reports have also found that breastfeeding is a major cause of sexual dysfunction in the postpartum period, which is in line with our findings [19]. In our study of affected women, it was found that psychological factors such as fear and anxiety were found in more than half of the affected women. This is in line with the current literature that highlights the multifactoriality of the postpartum sexual dysfunction, with the psychological, social, and cultural factors coming into contact with the physical factors [20]. Also, according to global health reports, over one-third of women have long-term postpartum complications, dyspareunia, and emotional distress, which are usually a result of poor follow-up care [21]. Interestingly, only 28% of participants in our study had undergone counseling, which could be the reason why the delay in resuming sexual activity was more prevalent. New evidence and study findings are highly in favor of incorporating postpartum sexual health counseling into the maternal care package since it is the most effective way of enhancing patient confidence and recovery [22]. Although our results confirm the linkage between episiotomy and postpartum dyspareunia, it is necessary to mention that other studies have indicated that episiotomy might prevent serious perineal tears, which in turn can adversely affect sexual functioning [23]. This means that the association between episiotomy and sexual outcomes is complicated and confounded by several factors.

Limitations

The single-center design and the rather small sample size were limitations of this study and can influence generalizability. The follow-up period (6 weeks) is short and might not indicate long-term results. Self-reports can bring about reporting bias. Absence of a control group and distinct measurement of psychological factors are other limitationst.

CONCLUSION :

Difficulty in resuming sexual intercourse is a common complication after episiotomy. In primigravida women, dyspareunia, poor healing, and psychological factors are the main causes of difficulty in resuming sexual intercourse. Early counseling, adequate perineal care, and specific interventions are necessary to enhance the postpartum sexual health, recovery, and quality of life of the affected patients.

Disclaimer: Nil

Conflict of Interest: Nil

Funding Disclosure: Nil

REFERENCE:

1. Jiang H, Qian X, Caroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017 Feb 8;2(2):CD000081. doi: 10.1002/14651858.CD000081.

2. Chaya Chinda C, Tita pant V, Ungkanungdecha A. Dyspareunia and sexual dysfunction after vaginal delivery in Thai primiparous women with episiotomy. J Sex Med. 2015 May;12(5):1275-82. doi: 10.1111/jsm.12860.

3. Gün İ, Doğan B, Özdamar Ö. Long- and short-term complications of episiotomy. Turk J Obstet Gynecol. 2016 Sep;13(3):144-148. doi: 10.4274/tjod.00087.

4. Turmon M, Echevarria M, Rubio P, Almeida C. Development of chronic pain after episiotomy. Rev Esp Anastasio Raeni. 2015 Oct;62(8):436-42. English, Spanish. doi: 10.1016/j.redar.2014.10.008.

5. Bespalova P, Kabanova J, Rusev Z, Pastor Z, Jans ova M, Kalis V. Mediolateral versus lateral episiotomy and their effect on postpartum coital activity and dyspareunia rate 3 and 6 months postpartum. Sex Repro’d Health. 2016 Jun; 8:25-30. doi: 10.1016/j.srhc.2016.01.004.

6. McDonald EA, Gartland D, Small R, Brown SJ. Dyspareunia and childbirth: a prospective cohort study. BJOG. 2015 Apr;122(5):672-9. doi: 10.1111/1471-0528.13263.

7. Rusev Z, Kabanova J, Kalis V. Timing of episiotomy and outcome of a non-instrumental vaginal delivery. Acta Obstet Gynecology Scand. 2016 Feb;95(2):190-6. doi: 10.1111/aogs.12814.

8. Naidu M, Kapoor DS, Evans S, Vinayaka Rao L, Thakar R, Sultan AH. Cutting an episiotomy at 60 degrees: how good are we? Int Urogynecology J. 2015 Jun;26(6):813-6. doi: 10.1007/s00192-015-2625-9.

9. O'Malley D, Higgins A, Smith V. Postpartum sexual health: a principle-based concept analysis. J Adv Nurs. 2015 Oct;71(10):2247-57. doi: 10.1111/jan.12692.

10. Fodstad K, Staff AC, Laine K. Sexual activity and dyspareunia the first year postpartum in relation to degree of perineal trauma. Int Urogynecology J. 2016 Oct;27(10):1513-23. doi: 10.1007/s00192-016-3015-7.

11. Meister MR, Rosenbloom JI, Lowder JL, Cahill AG. Techniques for Repair of Obstetric Anal Sphincter Injuries. Obstet Gynecology Surv. 2018 Jan;73(1):33-39. doi: 10.1097/OGX.0000000000000521.

12. Seijmonsbergen-Schermers AE, Saami S, Lucas C, Jonge Ad. No suturing or Skin Adhesives versus Suturing of the Perineal Skin After Childbirth: A Systematic Review. Birth. 2015 Jun;42(2):100-15. doi: 10.1111/birt.12166.

13. Marzouk T, Barakat R, Ragab A, Bardia F, Badawy A. Lavender-thymol as a new topical aromatherapy preparation for episiotomy: A randomised clinical trial. J Obstet Gynaecea. 2015;35(5):472-5. doi: 10.3109/01443615.2014.970522.

14. O'Malley D, Higgins A, Begley C, Daly D, Smith V. Prevalence of and risk factors associated with sexual health issues in primiparous women at 6 and 12 months postpartum; a longitudinal prospective cohort study (the MAMMI study). BMC Pregnancy Childbirth. 2018 May 31;18(1):196. doi: 10.1186/s12884-018-1838-6.

15. Sakala C. Longitudinal perspective is needed to improve postpartum health. BJOG. 2015 Apr;122(5):680. doi: 10.1111/1471-0528.13264.

16. Triviño-Juárez JM, Romero-Ayuso D, Nieto-Pereda B, Formas MJ, Oliver-Brachyuran C, Meliza-Díaz S, Avilés-Games B, Areti-Sevilla B, Criado-Álvarez JJ, Soto-Lucía C, Pal-Mestre R. Resumption of intercourse, self-reported decline in sexual intercourse and dyspareunia in women by mode of birth: A prospective follow-up study. J Adv Nurs. 2018 Mar;74(3):637-650. doi: 10.1111/jan.13468.

17. Kouakou KP, Doumbia Y, Danah LE, Menin MM, Danah Y. La sexuality du post-partum. Analyze du vice dans le couple noir African [post-partum sexuality. Living in black African couple analysis]. J Gynecology Obstet Biol Repro’d (Paris). 2015 Mar;44(3):280-5. French. doi: 10.1016/j.jgyn.2014.01.001.

18. Innan C, Agar MÇ, Sağır FG, Özer A, Özbek Ö, Dayani H, Uysal GS, Uysal O. Assessment of the Effects of Perineoplasty on Female Sexual Function. Balkan Med J. 2015 Jul;32(3):260-5. doi: 10.5152/balkanmedj.2015.15073.

19. Yassin K, Idris HA, Ali AA. Characteristics of female sexual dysfunctions and obstetric complications related to female genital mutilation in Omdurman maternity hospital, Sudan. Repro’d Health. 2018 Jan 8;15(1):7. doi: 10.1186/s12978-017-0442-y.

20. Dijk R, Henneman B, Russian M, Madani K, Disastrous M, de Leeuw JW, van Hof A. The MOVE-trial: Monocryl® vs. Vicarly Rapide™ for skin repair in mediolateral episiotomies: a randomized controlled trial. BMC Pregnancy Childbirth. 2017 Oct 16;17(1):355. doi: 10.1186/s12884-017-1545-8.

21. Kainu JP, Halmes maki E, Kotila KT, Sarvela PJ. Persistent Pain After Cesarean Delivery and Vaginal Delivery: A Prospective Cohort Study. Anest Analg. 2016 Dec;123(6):1535-1545. doi: 10.1213/ANE.0000000000001619.

22. Andelson K, Maricic Z. Posterior Fourchette Fissure Resolution After Injection of Autologous Adipose-Derived Regenerative Cells. Obstet Gynecol. 2017 Mar;129(3):497-499. doi: 10.1097/AOG.0000000000001906.

23. Selo-Ojime DO, Okonkwo CA, Taunya C, Ndukwe K. Single-knot versus multiple-knot technique of perineal repair: a randomised controlled trial. Arch Gynecology Obstet. 2016 Nov;294(5):945-952. doi: 10.1007/s00404-016-4101-2.

Difficulty in Resuming Sexual Intercourse After Episiotomy in Primigravida Patients

Article Information:

Abstract:

Keywords:

Article :

INTRODUCTION:

MATERIALS AND METHOD:

RESULTS:

DISCUSSION :

CONCLUSION :

REFERENCE:

Article Citation

APA

MLA

Chicago

Harvard

Vancouver