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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 4  |  Page : 1253-1257

Effect of different episiotomy techniques on perineal pain and sexual activity 3 months after delivery


1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menofia University, Menofia, Egypt
2 Department of Obstetrics and Gynecology, Ministry of Health, Berket Elsaba, Menofia, Egypt

Date of Submission11-May-2017
Date of Acceptance24-Jul-2017
Date of Web Publication14-Feb-2019

Correspondence Address:
Eman A Al-Sharkawy
Berket Elsaba, Menoufia, 32651
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_346_17

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  Abstract 


Objective
The aim of this study was to examine the relationship between different episiotomy techniques and sexual activity and perineal pain 3 months after delivery with episiotomy.
Background
Despite the controversy regarding the routine use of episiotomy-assisted delivery, it is still one of the commonly performed procedures worldwide.
Patients and methods
This study comprised a purposive sample of 150 uncircumcised, primigravida with episiotomy during normal delivery. These women were divided into three equal groups according to the type of episiotomy. The first group was patients with lateral episiotomy (N = 50), the second group was patients with mediolateral episiotomy (N = 50), and the last group was patients with median episiotomy (N = 50). The study was conducted at Obstetrics and Gynecology Department, at a Governmental Central Hospital. Two tools were used: a questionnaire containing sociodemographic data, episiotomy type, type of wound healing, vaginal dryness assessment, type of baby feeding, and sexual activity assessment, and pain assessment by visual analog scale.
Results
There was no difference in pain score distribution by visual analog scale when comparing midline, mediolateral, and lateral technique (P = 0.4). The study showed that 76.0% of the studied sample had a decreased coitus frequency. The main reason of coitus decrease was pain (49.0%). There was no statistically significant difference between type of episiotomy of the studied sample and postpartum sexual satisfaction (P = 0.2).
Conclusion
No difference was detected in perineal pain perception 3 months after delivery between different episiotomy techniques.

Keywords: delivery, episiotomy, pain perception, sexual behavior


How to cite this article:
Fahmy MM, Al-Lakwa HE, Al-Halaby AE, Al-Sharkawy EA. Effect of different episiotomy techniques on perineal pain and sexual activity 3 months after delivery. Menoufia Med J 2018;31:1253-7

How to cite this URL:
Fahmy MM, Al-Lakwa HE, Al-Halaby AE, Al-Sharkawy EA. Effect of different episiotomy techniques on perineal pain and sexual activity 3 months after delivery. Menoufia Med J [serial online] 2018 [cited 2024 Mar 29];31:1253-7. Available from: http://www.mmj.eg.net/text.asp?2018/31/4/1253/252047




  Introduction Top


Episiotomy's definition should include the point where the incision starts, its direction, depth and length, and the exact time the incision was performed[1].

Episiotomy is a surgical procedure in which the cut needs to be sutured, and is liable to complications such as infections and bleeding[2].

In developing countries, the obstetricians do episiotomies routinely to avoid perineal tear. Episiotomy is a surgical incision in the perineum to widen the vaginal orifice in order to shorten the period of baby delivery and prevent perineal tear[3],[4].

However, this policy has no infant or maternal benefit, but leads to postpartum perineal pain and its complications. The major advantage of routine use of episiotomy is avoidance of relaxation of pelvic floor and its complications such as urinary incontinence by reducing the risk of perineal trauma, as well as to facilitate vaginal delivery (especially in primigravida) by shortening the second stage of delivery, which protects the baby from birth asphyxia[5].

In developing countries such as Egypt, episiotomy is a common procedure to facilitate vaginal delivery. However, most of the reported studies found that it leads to side effects such as wound infection, delayed wound healing and gapping, severe perineal pain, postpartum dyspareunia and decreased sexual satisfaction, and fecal and/or urinary incontinence[3].

Different techniques of episiotomy can be used; the main types are defined as mediolateral, lateral, and median episiotomy. The difference between these types is the starting place and the angle of the incision[1].

In this study, we examine the relationship between three different episiotomy types and perineal pain and sexual activity 3 months postpartum with episiotomy.


  Patients and Methods Top


This study was approved by the Ethical Committee of Faculty of Medicine, Menoufia University, and informed consent was obtained from each participant after explanation of the purpose of the study. Data collected were used for the purpose of the research only. This study was fullified at Obstetrics and Gynecology Department, affiliated to a Governmental Central Hospital. It included a purposive sample of 150 uncircumcised, primigravida with episiotomy during normal delivery. These patients were divided into three equal groups according to the episiotomy type. The first group was patients with lateral episiotomy (N = 50), the second group was patients with mediolateral episiotomy (N = 50), and the last group was patients with median episiotomy (N = 50). The type of sutures that were used to repair the episiotomy were continuous sutures with vicryl(l) suture. Continuous suturing technique was not tightly taken; continuous nonlocking suture was used to close the vaginal mucosa, commencing above the apex of the incision by half centimeter and ending with a knot at the hymenal ring. The same suture was continued in the perineal muscles, which are sutured continuously reaching the end of the incision. The perineal skin was approximated with the same continuous suture a few millimeters under the perineal skin edges finishing with a terminal knot in the vaginal mucosa at the hymenal ring. Data were collected over a period of 10 months starting from January 2016 to October 2016.

Inclusion criteria were primiparas, full-term, uncircumcised, in labor, no cephalopelvic disproportion, no indication of cesarean section, and expected fetal weight not more than 3.5 kg (assessed by ultrasound).

Exclusion criteria were multigravida women, circumcised ladies, history of injury of external anal sphincter or anal canal, varicose veins of the perineum, and patients who have sexually transmitted diseases.

To collect data pertinent to this study, we developed and used the following questionnaire that contains three sections. The first section was performed to cover the sociodemographic data of the women such as name, age, address, and contact numbers. In addition, it contains the assessment of the labor type and the episiotomy type. This section was to be completed immediately after delivery.

The second section was developed to assess the healing of episiotomy wound and to detect any signs of infection as redness, hotness, tenderness, and swelling, the presence of pus discharge, or the presence of bad odor. This section was conducted 2 weeks after delivery at the outpatient clinic.

The third part was assessing the presence of perineal pain using visual analog scale (VAS) and the sexual activity of the participant; assessing the date of resuming coitus, its frequency, and reasons of coitus decreasing if present; and assessing the vaginal dryness and sexual satisfaction by direct question to the patient. It also asked about the baby feeding type, as it can affect the sexual activity. The third section of the questionnaire was conducted 3 months postpartum at the outpatient clinic. A careful pain assessment was performed by using VAS. The VAS score from 0-10 was obtained from the patients. A higher score indicates greater pain intensity. The following cut points on the pain VAS have been recommended: no pain (0–4 mm), mild pain (5–44 mm), moderate pain (45–74 mm), and severe pain (75–100 mm).

Statistical analysis

After finishing the data collection, the data were analyzed by using statistical package for the social sciences program version 20 for windows (SPSS; SPSS Inc., Chicago, Illinois, USA) and then tabulated. Relevant statistical analysis was used to test the obtained data. Descriptive and inferential statistics were done such as mean and SD, frequency, percentage, χ2-test, t-test, and Pearson's correlation coefficient test (r). A significant level value was considered when P value is less than 0.05.


  Results Top


Distribution of the studied sample based on their age revealed that most of them (96.0%) were in the age group of 15–25 years. Regarding the type of labor, the majority of the studied sample (92.7%) was spontaneous labor. As regards wound healing, 93.5% of the spontaneous labor episiotomy wound healed with primary intention; in contrast, 91% of the instrumental labor episiotomy wound healed with secondary intention [Table 1].
Table 1: Number and percentage distribution of the studied sample according their age type of labor and wound healing (n=150)

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About one-third of the studied sample (38.0%) had mild degree of pain at the site of episiotomy scar. Sexual intercourse was the most precipitating factor (36.0%) [Table 2].
Table 2: Number and percentage distribution of the studied sample according their pain degree at the site of episiotomy scar and precipitating factor of pain (n=150)

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In relation between episiotomy type and the pain degree, there was no statistically significant difference between episiotomy type and pain degree in the studied sample (χ2 = 5.79, P = 0.4), whereas pain with intercourse was the highest precipitating factor for pain in all types of episiotomy (lateral: 32%, mediolateral: 42% and median: 34%). There was a high statistically significant difference between episiotomy type and the precipitating factor of the pain in the studied sample (χ2 = 63.4, P = 0.0001). Pain with intercourse was more with mediolateral (14%) than with lateral episiotomy (10.7%). However, pain during walking and intercourse was more with lateral episiotomy (2.7%), whereas pain with defecation and intercourse was more with median episiotomy (10%) [Table 3].
Table 3: Relation between type of episiotomy of the studied sample and their pain degree and its relation with the precipitating factors of pain (n=150)

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There was no statistically significant difference between episiotomy type and intercourse satisfaction in the studied sample (χ2 = 5.85, P = 0.2). There was a highly statistically significant difference between episiotomy type and the vaginal dryness in the studied sample (χ2 = 41.34, P = 0.0001), as it was more with lateral and mediolateral episiotomy [Table 4].
Table 4: Relation between type of episiotomy of the studied sample and their intercourse satisfaction and vaginal dryness

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There was a high statistically significant difference between intercourse satisfaction in the studied sample and their type of baby feeding (χ2 = 101.7, P = 0.0001). Women who use artificial baby feeding suffered less from decreasing sexual satisfaction [Table 5].
Table 5: Relation between intercourse satisfaction of the studied sample and their type of baby feeding (n=150)

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  Discussion Top


The current study revealed that the majority of the studied sample were of age ranging between 15 and 25 years. This may be because of the restricted inclusion criteria that included only the primigravida women, and this study was conducted in a traditional area where the women married early.

The current study revealed that more than three quarters of them (92.7%) had a spontaneous labor and 93.5% of them had primary intension wound. In all, 7.3% of the studied sample had instrumental delivery by ventouse, and all of them healed by secondary intension. These results are similar to those of Ahmed and Mohamed[6], who mentioned that about three quarters of women with episiotomy showed optimal wound healing.

In contrast, Acele and Karaçam[7] reported that one-third of women with episiotomy had problems with wound healing and less than one-quarter had delayed wound healing in the third postpartum week.

From the researcher's point of view, most cases showed optimal wound healing as we guarded against infection and avoided unnecessary tissue trauma; the cases who had instrumental delivery had delayed wound healing because of excessive tissue manipulation.

In relation between episiotomy type in the studied sample and their precipitating factor for pain, it was noted that there is a highly statistically significant difference between types of episiotomy and the precipitating factors for pain. Pain with intercourse was more with mediolateral than with lateral episiotomy. However, pain during walking and intercourse was more with lateral episiotomy, whereas pain with defecation and intercourse was more with median episiotomy.

The study by Ratchadawan et al.[8] revealed that there was no difference in pain VAS scores between the two groups of mediolateral and midline episiotomies. Wound infection occurred only in one patient in the group of mediolateral episiotomy. After 6 weeks postpartum to assess the results, no statistically significant difference between the two groups was found regarding pain scores (median 0, range 0–5 in the mediolateral group vs median 0, range 0–1 in the midline, P = 0.13) and according to sexual satisfaction relation with the episiotomy types (99.1% in the group of mediolateral vs 100% in the midline).

Aytan et al.[9], found that, 3% of midline episiotomies complaining from severe perineal lacerations versus 1% in mediolateral episiotomies.

A similar result was revealed in another study, in which fatigue and exhaustion, in addition to associated perineal pain and dyspareunia, depression, and breastfeeding led to a decrease in sexual satisfaction[7],[10],[11].

This study showed distribution of members in the studied sample depending on their intercourse satisfaction and vaginal dryness, which revealed that more than two-thirds of them sometimes had intercourse satisfaction and half of them sometimes had vaginal dryness. From the researcher point of view, postpartum vaginal dryness increased the incidence of dyspareunia and interfered with sexual satisfaction. Ejegård et al.[12] found that episiotomy and second-degree perineal lacerations increase the rate of postpartum dyspareunia 12–18 months postpartum. Most cases of postpartum dyspareunia are related to local injury of the genitalia, such as suturing, or due to vaginal inflammation or infection and vaginal dryness.

Studies confirm these findings claiming that perineal injury, with or without suturing, forceps delivery, and episiotomy are risk factors that increase the rate of postpartum vaginal dryness, insufficient sexual satisfaction, and persistent dyspareunia[10],[11],[12].

The result of this study illustrated that more than two-thirds of them used natural breastfeeding and artificial feeding. Heidari et al.[13] indicated that rather less than one-third of breastfeeding women and one-quarters of nonbreastfeeding women resumed their sexual activity in 1 month postpartum and there was no significant difference between the two groups of women in the date of sexual activity resumption.


  Conclusion Top


From the presented results we can concluded that there is no significant difference in perineal pain perception 3 months after delivery between different episiotomy techniques.

Also, no significant difference was detected in sexual satisfaction and the coitus decreasing 3 months after delivery between the different episiotomy techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kalis V, Stepan J Jr, Horak M, Roztocil A, Kralickova M, Rokyta Z. Definitions of mediolateral episiotomy in Europe. Int J Gynaecol Obstet 2008; 100:188–189.  Back to cited text no. 1
    
2.
Wegnelius G, Hammarström M. Complete rupture of anal sphincter in primiparas: long-term effects and subsequent delivery. Acta Obstet Gynecol Scand 2011; 90:258–263.  Back to cited text no. 2
    
3.
Saxena RK, Sandhu GS, Babu KM, Bandol H, Sharma GV. Restricted use of episiotomy. J Obstet Gynaecol India 2010; 60:408–412.  Back to cited text no. 3
    
4.
Carvalho CC1, Souza AS, MoraesFilho OB. Prevalence and factors associated with practice of episiotomy at a maternity school in Recife, Pernambuco, Brazil. Rev Assoc Med Bras (1992) 2010; 56:333-339.  Back to cited text no. 4
    
5.
Bertozzi S, Londero AP, Fruscalzo A, Driul L, Delneri C, Calcagno A, et al. Impact of episiotomy on pelvic floor disorders and their influence on women's wellness after the sixth month postpartum: a retrospective study. BMC Women's Health 2011; 11:12.  Back to cited text no. 5
    
6.
Ahmed AA, Mohamed SH. Routine episiotomy for vaginal birth: should it be ignored? IOSR-JNHS 2015; 4:70–77.  Back to cited text no. 6
    
7.
Acele EÖ, Karaçam Z. Sexual problems in women during the first postpartum year and related conditions. J Clin Nurs 2012; 2:929–937.  Back to cited text no. 7
    
8.
Sooklim R, Thinkhamrop J, Lumbiganon P, Prasertcharoensuk W, Pattamadilok J, Seekorn K, et al. The outcomes of midline versus medio-lateral episiotomy. Reprod Health 2007; 4:10.  Back to cited text no. 8
    
9.
Aytan H, Tapisiz OL, Tuncay G, Avsar FA. Severe perineal lacerations in nulliparous women and episiotomy type. Eur J Obstet Gynecol Reprod Biol 2005; 121:46–50.  Back to cited text no. 9
    
10.
Vettorazzi J, Marques F, Hentschel H, Ramos JGL, Martins-Costa SH, Badalotti M. Sexuality and the postpartum period: a literature review. Rev HCPA 2012; 32:473–479.  Back to cited text no. 10
    
11.
Leeman LM, Rogers RG. Sex after childbirth: postpartum sexual function. Obstet Gynecol 2012; 119:647–655.  Back to cited text no. 11
    
12.
Ejegård H, Ryding EL, Sjogren B. Sexuality after delivery with episiotomy: a long-term follow-up. Gynecol Obstet Invest 2008; 66:1–7.  Back to cited text no. 12
    
13.
Heidari M, Khoei EM, Asiabar AK. What happens to sexuality of women during lactation period? A study from Iran. Pak J Med Sci 2009; 25:938–943.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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