U J - Spring 2012.pdf 498 | Female Urology Sexual Function of Primiparous Women After Elective Cesarean Section and Nor- mal Vaginal Delivery Ladan Hosseini,1 Elham Iran-Pour,2 2 Purpose: To compare sexual function between two groups of women who had Materials and Methods: In this cross-sectional study, two groups of healthy wom- en, with antenatally normal singleton pregnancies at term, who underwent NVD function of participants was assessed using physician-administered Female Sexual questionnaire. Secondary outcome measures included the remaining items. Results: function, including desire (P P P - gasm (P P P Eighty percent of women who had undergone vaginal delivery complained from Conclusion: We believe that PCS is not preferred to NVD in regard to preserving normal sexual functioning. Keywords: women’s health, cesarean section, postpartum period, sexual dysfunc- tion, sexual behavior Corresponding Author: Mohammad Reza Safa- rinejad, MD P.O. Box 19395-1849, Tehran, Iran Tel: +98 21 2245 4499 Fax: +98 21 2245 6845 E-mail: info@safarinejad. com Received June 2011 Accepted November 2011 1School of Nursing and Midwifery, Tehran Univer- sity of Medical Sciences, Tehran, Iran 2Private Practice of Urology and Andrology, Tehran, Iran Female Urology 499Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L Mode of Delivery and Sexual Function | Hosseini et al INTRODUCTION Sinability to achieve or enjoy orgasm. The accurate prevalence of female sexual dys- function is unknown; however, in our community 31.5% of women suffer from some types of FSD. - tal, and social aspects of individuals’ lives; hence, nowadays more attention is given to the sexual health. Some studies have reported that sexual health may be affected by the mode of delivery. The puden- dal nerve which innervates the clitoris, vulva, and perineum, may be damaged during vaginal de- livery by infant’s head pressure and/or forceps. Furthermore, hypotonic muscles of the vagina due to vaginal prolapse can lead to decreased ability to achieve orgasm. Adverse effects of vaginal delivery on sexual function have been reported previously. These studies have demonstrated that undergoing cesar- normal sexual function, and maintains anatomical intrapelvic organs. Accordingly, CS has high popularity and attitudes of women, midwives, and obstetricians have changed towards CS. A recent English survey found that 33% of obstetri- - ner. About 80% to 93% of women restart their sexual - ery. During this period, about two-thirds of wom- en experience at least one sexual dysfunction, such as vaginal dryness, pain, decreased libido, and lack of orgasm. Many researchers believe that problems, such as dyspareunia, low back pain, and sexual dysfunction, are due to the pel- or pudendal nerve damage during normal vaginal dyspareunia after CS. Other studies have shown a relationship between dyspareunia and NVD. - ual dysfunction six months after delivery, which may be due to conditions like reduced serum level of progestin, emotional factors, breastfeeding, or changes in body image after childbirth. There are limited studies about long-term effects of two types of deliveries on sexual function with different results being reported. Dean and col- leagues showed that six years after delivery, sexu- al satisfaction and vaginal muscles tone are signif- icantly less in women with NVD than the women who had undergone a CS. On the other hand, - lationship in sexual function among women with different types of delivery six months to two years after delivery. function after the NVD and CS, we aimed to com- pare sexual function in women after the NVD and PCS. MATERIALS AND METHODS In this cross-sectional study, we compared sexual Ethics Committee of Tehran University of Medi- referred to the health clinics at Tehran University of Medical Sciences were recruited consecutively. The participants were informed of the purpose of the study and gave their informed consent. Fur- Inclusion criteria were being in the age range of 19 - to Tehran University of Medical Sciences with live children, no history of stillbirth or miscarriage, and living with the husband. The exclusion criteria 500 | included having a child with anomalies, preterm delivery, previous pelvic surgery, history of pre- vious marriage, history of subfertility, body mass index > 30, consuming medications with adverse effects on sexual function (eg, blood pressure low- ering drugs, anti-arrhythmia drugs, sedative drugs, mental problems, presence of relationship prob- lem with husband, mental retardation, smoking and alcohol consumption, and having a critical incident, such as the death of relatives in the past year. All of the subjects should have normal sexual functioning before pregnancy according to female - teria and recruited into the study. Data were col- lected using a physician-administered question- demographic characteristics and FSFI questions. The demographic characteristics included age, educational level, spouse’s educational level, oc- cupational status, spouse’s employment, duration of marriage, monthly income, type of delivery, in- fant’s gender, weight and head circumference at birth, contraceptive methods used, and history of breastfeeding. The sexual function of women were assessed us- ing FSFI in six domains including: 1. Sexual ori- - - sion of the questionnaire as follows: The items 1 - ual items that comprise the domain and multiply- ing the sum by domain factor obtained individual domain score. Factors were 0.6 for desire, 0.3 for and satisfaction. The full-scale score range was - pleted in a private setting. Statistical Analysis unless otherwise stated. Differences in variables between groups were determined with the Stu- dent’s two tailed t test and One-way ANOVA for dichotomous and normally distributed continuous variables, respectively. Proportions were com- pared using Chi-Square test. Analysis of variance between means in groups. For obtaining adjusted P values, a multivariable regression model was used to adjust for potential confounding factors. Statistical analysis was performed using the SPSS software (the Statistical Package for the Social Sciences, Version 17.0, SPSS Inc, Chicago, Illi- P values less than .05 were consid- P values are adjusted for confounding factors, namely, age, du- ration of marriage, educational level, contracep- tion methods, and occupational status. RESULTS The baseline characteristics of the patients who completed the study protocol are shown in Table - in both groups. A majority of the participants had at least high school education, were housewives, and used natural method for contraception. Most of the women had breastfed their children. The majority of the participants had duration of less (P - ferent domains of sexual function, including sexu- Female Urology 501Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L al desire (P P - nal lubrication (P (P P disorder (P - tween the overall sexual function scores between the two groups of women (P Regarding the question that asked whether the NVD had any adverse effect on their sexual func- tion and the reproductive tract, of patients in NVD - adversely affected their sexual function. We also examined whether breastfeeding confounded the observed associations. The correlation between breastfeeding and total FSFI scores with mode of P P DISCUSSION - tween childbirth to six weeks later. Postpartum period health is prospectively divided into three from six weeks to six months after delivery (short- We studied the effect of mode of delivery on sexual functioning during long-term postpartum period. In this study, the subjects either had NVD with a mediolateral episiotomy or underwent PCS. The results of this study showed that women in the NVD group and the women with CS had no function, including sexual desire, sexual arousal, vaginal lubrication, sexual satisfaction, pain, and orgasm. In a study by Hannah and colleagues, the results of sexual function three months to two years postpartum among women who had under- gone NVD and CS. Furthermore, other studies showed that mode of delivery was not an affecting factor on sexual function after one year of deliv- Mode of Delivery and Sexual Function | Hosseini et al Table 1. Demographic characteristics. Variables Normal Vaginal Delivery (n = 114) Planned Cesarean Section (n = 99) P Mean age, y 25 ± 3.2 25 ± 3.4 .92 Duration of marriage, y 3 ± 1.7 3 ± 1.5 Education level, n (%) Primary school 0 (0.0) 0 (0.0) ------ High school .74 Graduate 20 (17.5) 16 (16.2) .073 Contraception methods, n (%) Condom 26 (26.3) .067 OCP 13 (11.4) .072 IUD 25 (21.9) 27 (27.3) .032 Withdrawal 35 (35.4) .43 Others 3 (3.0) .054 Occupational status, n (%) Unemployed 72 (72.7) .71 Employed 29 (25.4) 27(27.3) .43 502 | ery. Safarinejad and associates evaluated the effect of the mode of delivery on the quality of life, sexual function, and sexual satisfaction in primiparous women and their husbands. They concluded that women with vaginal delivery and emergency CS - - tionship between the type of delivery and sexual function six months after delivery. - ings differ from the results of the present study. This may be due to small number of subjects, dif- ferent type of study population, a restricted age range of the population, and differences in study design. Our study assessed the sexual function up to two years after delivery; however, the mentioned studies were carried out during six months to one year postpartum. Therefore, the decreased sexual function may be due to the reduced progesterone as a result of breastfeeding or emotional factors, such as changes in self-image, the relationship be- tween the partners, and altered body image early in childbirth. It is also reported that the fear of women after NVD results in increasing frustration and pain and decreasing sexual desire and vaginal lubrication, which usually disappear within the Women who had undergone NVD were not satis- impact on sexual satisfaction was low. It is clear - cia and nerves are unavoidable consequences of - pressure of fetal head. These forces cause func- tional changes in nerves, muscles, and connective tissues and result in relaxation of the vagina and inability to achieve orgasm in women. The or- gasm is described as the most gratifying sexual feeling. This feeling require answers from smooth and skeletal muscles during the sexual stage of motivation. During orgasm, rhythmic contractions - tor ani and anus. Accordingly, the reduced tone can result in inability to reach orgasm. According to the study by Signorello and col- leagues, the degree of perineal injury during as- sisted vaginal delivery was correlated with the ability to have orgasm. We excluded the women who had assisted vaginal deliveries and who had 3rd th-degree lacerations from our study. Fur- thermore, we did not measure the muscle tone. Table 2. Domain scoring of FSFI in 24-month follow-up.† FSFI domains Normal Vaginal Delivery Planned Cesarean Section P* Desire 6.09 ± 1.31 .55 Arousal 9.57 ± 2.05 .39 Orgasm 10.05 ± 2.13 9.79 ± 1.96 .36 Pain 9.42 ± 2.4 9.54 ± 2.59 .74 Lubrication 12.11 ± 2.16 .45 Satisfaction .39 Sexual function 21.39 ± 3.13 21.34 ± 2.70 .91 † FSFI indicates female sexual function index. * P methods, and occupational status. Female Urology 503Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L between the women with NVD and women who had undergone PCS. Baytur and associates report- reduced in women with NVD; however, there was muscle tone and sexual dysfunction. Dean and coworkers also reported that six years after deliv- ery, sexual satisfaction and vaginal muscle tone comparing to those with CS. One advantage of this study was using valid Per- sian version of the FSFI questionnaire. Further- more, we controlled the impact of age by limit- also tried to control other confounding factors on sexual function, such as employment status, edu- cational level, and monthly income. This study has some limitations. First, it was a self-reported survey. We made every effort to ex- plain all the questionnaire items to the participants to obtain valid responses. The second limitation of the study is that we did not address the husbands’ views. The third drawback is that we had no equip- ments to measure the muscle tone exactly. Finally, we did not study the sexual function across differ- ent parities. CONCLUSION We concluded that women with NVD were less to the women who had PCS. However, there was delivery and the six domains of sexual function between the two groups. Therefore, it can be sug- gested that NVD has little impact on the sexual function of the women two years after delivery. Hence, undergoing PCS in order to preserve sexu- al function is not recommended. CONFLICT OF INTEREST None declared. REFERENCES 1. Buhling KJ, Schmidt S, Robinson JN, Klapp C, Siebert G, Dudenhausen JW. Rate of dyspareunia after delivery in primiparae according to mode of delivery. Eur J Obstet 2. based study in Iran: prevalence and associated risk factors. 3. mode of delivery on the quality of life, sexual function, and sexual satisfaction in primiparous women and their 4. Pollack J, Nordenstam J, Brismar S, Lopez A, Altman D, Zetterstrom J. Anal incontinence after vaginal delivery: a five-year prospective cohort study. Obstet Gynecol. 5. Gungor S, Baser I, Ceyhan T, Karasahin E, Kilic S. Does mode of delivery affect sexual functioning of the man partner? J 6. Wagner M. Choosing caesarean section. Lancet. 7. Lavender T, Kingdon C, Hart A, Gyte G, Gabbay M, Neil- son JP. Could a randomised trial answer the controversy relating to elective caesarean section? National survey of consultant obstetricians and heads of midwifery. BMJ. Abraham S. Recovery after childbirth. Med J Aust. 9. Clark MH, Scott M, Vogt V, Benson JT. Monitoring pudendal 9. 10. Abraham S, Child A, Ferry J, Vizzard J, Mira M. Recovery after childbirth: a preliminary prospective study. Med J 11. Klein MC, Gauthier RJ, Robbins JM, et al. Relationship of episiotomy to perineal trauma and morbidity, sexual dys- function, and pelvic floor relaxation. Am J Obstet Gynecol. 12. Barrett G, Pendry E, Peacock J, Victor C, Thakar R, Manyonda I. Women's sexuality after childbirth: a pilot study. Arch Sex Mode of Delivery and Sexual Function | Hosseini et al 504 | Female Urology 13. Dean N, Wilson D, Herbison P, Glazener C, Aung T, Mac- arthur C. Sexual function, delivery mode history, pelvic floor muscle exercises and incontinence: a cross-sectional study six years post-partum. Aust N Z J Obstet Gynaecol. 14. Baytur YB, Deveci A, Uyar Y, Ozcakir HT, Kizilkaya S, Caglar H. Mode of delivery and pelvic floor muscle strength and sexual function after childbirth. Int J Gynaecol Obstet. 15. Rosen R, Brown C, Heiman J, et al. The Female Sexual Func- tion Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital 16. A comparison of sexual outcomes in primiparous women experiencing vaginal and caesarean births. Indian J Com- 17. Hannah ME, Whyte H, Hannah WJ, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the interna- tional randomized Term Breech Trial. Am J Obstet Gynecol. van Brummen HJ, Bruinse HW, van de Pol G, Heintz AP, van der Vaart CH. Which factors determine the sexual function 19. Baksu B, Davas I, Agar E, Akyol A, Varolan A. The effect of mode of delivery on postpartum sexual functioning in pri- miparous women. Int Urogynecol J Pelvic Floor Dysfunct. 20. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J