International Urogynecology Journal

https://doi.org/10.1007/s00192-019-03894-0

REVIEW ARTICLE

Incidence of perineal pain and dyspareunia following spontaneous

vaginal birth: a systematic review and meta-analysis
Margarita Manresa 1 & Ana Pereda 1 & Eduardo Bataller 2,3 & Carmen Terre-Rull 4 & Khaled M. Ismail 5 & Sara S. Webb 6,7

Received: 19 November 2018 / Accepted: 28 January 2019

# The International Urogynecological Association 2019

Abstract
Introduction and hypothesis Perineal pain and dyspareunia are experienced by women undergoing a vaginal birth that can have
short and longer term physical and psychological morbidities. This review aimed to determine the incidence of perineal pain and
dyspareunia following spontaneous vaginal birth (SVB) with intact perineum, first and second-degree perineal trauma or
episiotomy.
Methods Searches of MEDLINE, EMBASE, CINAHL, AMED and MIDIRS (inception – December 2017) were undertaken
with selection criteria of any study evaluating the effect of intact perineum, first- or second-degree perineal trauma on perineal
pain or dyspareunia in women with SVB.
Results Eighteen studies (8 RCTs and 10 NRSs) were included. Fourteen and 12 studies were undertaken to assess perineal pain
and dyspareunia after SVB, respectively. Meta-analysis of 16 studies (3133 women) demonstrated that women at 2 days
postpartum experienced nearly the same incidence of perineal pain whether perineal trauma existed or not. At 4–10 days
postpartum there was a significant reduction in the incidence of perineal pain for both presence and absence of any perineal
trauma. Episiotomy was associated with the highest rate of perineal pain. The incidence of dyspareunia was high at resumption of
sexual intercourse following SVB with an intact perineum. At 12 months, women still experienced dyspareunia whether perineal
trauma existed or not.
Conclusions Women experience perineal pain and dyspareunia regardless of the presence or absence of perineal trauma after
SVB; nonetheless, the reported incidence is higher if perineal trauma occurred.

Keywords Perineal trauma . Perineal pain . Dyspareunia . Spontaneous vaginal birth . Systematic review

Introduction births per annum [1–5]. Childbirth is always an expected

event full of emotions although not free of fears.
Worldwide just over 60% of women have a spontaneous vag- Psychological concerns such as changing lifestyles, body im-
inal birth (SVB) equating to an estimate of 78.84 million age issues and psychosocial problems exist alongside physical

Conference Presentations IUGA 43rd Annual Meeting, Vienna,

Austria. 27–30 June 2018.
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s00192-019-03894-0) contains supplementary
material, which is available to authorized users.

* Margarita Manresa 4
Facultad de Medicina y Ciencias de la Salud: Escuela de Enfermería,
[email protected] Universitat de Barcelona, Barcelona, Spain
5
Faculty of Medicine, Ain Shams University, Cairo, Egypt
1
Hospital General de Granollers, Carrer Francesc Ribas, s/n, 08402
6
Granollers, Barcelona, Spain Institute of Applied Health Research, College of Medical and Dental
2 Sciences, University of Birmingham, Birmingham, UK
Hospital Clínic i Provincial de Barcelona, Barcelona, Spain
3 7
Facultad de Medicina y Ciencias de la Salud, Universitat de Birmingham Women’s NHS Foundation Trust, Edgbaston,
Barcelona, Barcelona, Spain Birmingham, UK
 Int Urogynecol J

concerns and morbidities of extreme tiredness, urinary and perineal trauma or episiotomy. However, limiting our search
anal incontinence, wound infection or dehiscence, perineal to RCTs would have only enabled data capture for women
pain or dyspareunia [6, 7]. who sustained second-degree trauma or an episiotomy.
Perineal pain and dyspareunia are commonly experienced Therefore, a decision was made to include both randomised
in both the short and longer term by women undergoing a controlled trials (RCTs) and non-randomised studies (NRSs)
vaginal birth. Perineal pain can limit the woman’s mobility, reporting incidence of perineal pain or dyspareunia after SVB.
quality of life and ability to comfortably care for her baby, Case series and case reports were excluded. Conference pa-
which can have a negative impact on a mother’s adaptation pers and abstracts were included if they reported enough in-
to her new role [8]. Likewise, dyspareunia is usually reported formation regarding study design and outcome data. No lan-
in the long-term postnatal period, which can affect sexual guage restrictions were applied, but the search was limited to
health and relationships [9, 10]. human studies. The search strategies were developed by MM.
Evidence shows that there is a significant association be- A database of all abstracts of citations was compiled.
tween perineal pain and dyspareunia and operative vaginal
birth [11, 12]. Moreover, the best material and method to
Study selection
repair perineal trauma to reduce the incidence of perineal pain
and dyspareunia following childbirth have been heavily
Studies were selected in a three-stage process. First, each title
researched [13, 14]. However, the incidence and ongoing rates
and abstract were assessed by two reviewers (MM and AP)
of perineal pain and dyspareunia after SVB particularly when
and full articles of all references that were likely to fulfil
the perineum is intact are less clearly known.
predefined criteria were obtained. Second, selected articles
This review aimed to systematically assess the current
were assessed by two independent reviewers (MM and AP),
available evidence to determine the incidence of perineal pain
against pre-designed inclusion/exclusion criteria, with any
and dyspareunia, at both the short and long term, following
discrepancies referred to a third party (SSW, EB or KMI) for
SVB with an intact perineum, first- and second-degree peri-
the final decision. Third, studies were included if they gave
neal trauma or episiotomy.
information with supporting statistical evidence on perineal
pain or dyspareunia for women after SVB. When necessary,
the study’s author was contacted to clarify or obtain additional
Materials and methods
data (Fig. 1).
Search strategy
Data abstraction and synthesis
A protocol using widely recommended methods for system-
atic reviews of observational studies was developed and reg- Data were extracted on study quality, participants’ character-
istered with PROSPERO International prospective register of istics, perineal trauma repair techniques, perineal pain includ-
systematic reviews (CRD42017054281). The PRISMA state- ing pain at different time periods and settings, use of analgesia,
ment and checklist were followed throughout review prepara- breastfeeding and dyspareunia using a pre-designed data cap-
tion (Appendix 1). ture form. Data extraction was performed by two reviewers
MEDLINE, EMBASE, CINAHL, AMED and Maternity (MM and AP), with assistance from a third reviewer in case of
and Infant Care (MIDIRS) databases were searched electron- discrepancy (SSW). Primary outcomes were perineal pain and
ically from inception to December 2017. A combination of dyspareunia after SVB. Perineal pain was defined as pain in
medical subject headings (MeSHs), to encompass both peri- the area reaching from the symphysis pubis to the coccyx and
neal pain and dyspareunia, keywords and word variants using across both ischial tuberosities [7, 15]. We chose this defini-
Boolean operators ‘OR’ and ‘AND’ to capture relevant text tion, which is different from that suggested by the
citations were used. Search strategies were adapted for each International Urogynecology Association (IUGA) and the
database (Appendix 2). Terms of ‘sphincter anal’ or ‘Obstetric International Continence Society (ICS) [16] who both define
Anal Sphincter InjurieS (OASIS)’ or ‘operative vaginal birth’ it as the area between the posterior fourchette (posterior lip of
were not included in the search to reduce the risk of limiting the introitus) and the anus, in order to encompass pain related
access to all possible relevant articles. In addition, reference to perineal trauma when it occurs in the anterior perineum and
lists of relevant articles were manually searched to identify to reflect the correct anatomical definition of the perineum.
papers not captured by electronic searches. The aim of our We used the dyspareunia definition of persistent or recurrent
systematic review was to assess the current evidence to deter- pain or discomfort associated with attempted or complete vag-
mine the incidence of perineal pain and dyspareunia at both inal penetration [16]. When extracting data it was noted how
the short and long term, following spontaneous vaginal birth the studies defined perineal pain and dyspareunia. Whenever
with either an intact perineum, first- and second-degree possible, data were extracted to compute 2 × 2 tables.
Int Urogynecol J

I dentification
Records idenfied through Addional records idenfied
database searching through other sources
(n = 1841) (n = 9)

Records aer duplicates removed

(n = 1142)
Screening

Records excluded aer screening

Records screened tles & abstracts as did not
(n = 1142) match inclusion criteria
(n = 876)

Full-text arcles excluded, did not

Full-text arcles assessed provide adequate data for inclusion
criteria
Eligibility

for eligibility (n = 248)

(n =266) Primary reason for exclusion:
Did not include degree of perineal
trauma (n =29)
Did not report material and
technique suture (n = 103)
Did not measure postpartum perineal
Studies included in
pain or dyspareunia related any
qualitave synthesis degree of perineal trauma (n =33)
(n = 18) Others (n = 83)
Included

Studies included in quantave synthesis

(meta-analysis) (n = 16):
Perineal pain aer SVB (n = 14)
Dyspareunia aer SVB (n = 12)

Fig. 1 PRISMA 2009 flow diagram

Although all studies used the Royal College Obstetricians the repairs were performed using a recommended absorbable
and Gynaecologists (RCOG) classification for categorising suture material, the different interpretations of ‘continuous
perineal trauma, some studies undertook analysis by using repair technique’ necessitated analysing incidence of perineal
alternative terminologies to describe the trauma or grouping pain and dyspareunia in the following three repair technique
the trauma for analysis. In five studies (27.7%) data were categories: (1) continuous technique for all layers (vaginal
presented as spontaneous tear or perineal laceration [17–19] mucosa, perineal muscles and skin), (2) continuous technique
or as sutured/unsutured tears [11, 20], whilst in six studies [11, for vaginal mucosa only and (3) episiotomy repaired, at least,
21–25] data on second-degree perineal trauma and episiotomy with the continuous technique for subcutaneous tissue. No
were grouped. We contacted authors requesting the informa- other different repair techniques were found within studies
tion be stratified by degree of trauma. However, in the major- that met inclusion criteria for this SR.
ity of cases (72.7%), authors either could not provide this data
or did not respond to our request. Validity assessment
Regarding second-degree perineal trauma and episiotomy,
initially, our aim was to determine the incidence of the peri- The Cochrane Collaboration’s tool for assessing risk of bias in
neal pain and dyspareunia in relation to whether the trauma randomised trials [28] and the Joanna Briggs Institute
was repaired in line with Spanish National Healthcare System Prevalence Critical Appraisal Tool (Table S1) [29] were used
and RCOG evidence-based guidelines [26, 27]. Although all to asses risk bias and quality of included RCTs and NRSs
 Int Urogynecol J

respectively. Quality assessment was then used to assess the (12.5%) fulfilled five criteria. The remainder (62.5%) met four
methodological adequacies of the included studies and assist or less of the quality criteria. One study failed to fulfil any of
with interpretation of meta-analysis findings and possible bias the quality criteria. For the NRSs, no studies met all ten quality
resultant from study heterogeneity. criteria. Two studies (20%) met seven or more criteria; the
remainder fulfilled six or less, where three studies (30%)
Statistical methods met < 50% of quality criteria. No studies were excluded from
the systematic review for failure to fulfil the quality criteria.
R version 3.4.3 [30] with packages meta [31] and metaphor Validated measurement tools for perineal pain and
[32] were used for statistical analysis. Meta-analysis was per- dyspareunia were only used in nine studies (64.3%) and four
formed if data from two or more eligible studies were avail- studies (33.3%), respectively.
able; all other eligible studies were analysed descriptively. The Regarding the definition of the perineal area or perineal
number of positive events and the total number of potential pain used in the questionnaires, only three studies [18, 37,
events (namely, women with the condition and total women 38] detailed the specific area related to the perineum, albeit
examined) were analysed and summarised with the resulting not clearly defined. Regarding dyspareunia, the majority of
incidence rate and its 95% confidence interval (CI). Meta- the studies reported on pain during sexual intercourse, similar
analytical estimates of the overall incidence rate (point esti- to the ICS definition.
mate and 95% CI) were obtained fitting random-effects Only four studies provided information on sample size
models because of the high likelihood of clinical and statistical calculations.
heterogeneity; the inverse variance (IV) method with log
transformation of the incidence rate was used. The preferred
measure of statistical heterogeneity in the meta-analysis was Principal results
the I2 statistic (and, if obtainable, its 95% CI) [33]. Values
below 25% were considered low, about 50% moderate and Perineal pain after SVB
above 75% high [34]. Cochrane’s Q statistic was reported as
a χ2 with its corresponding degrees of freedom and resulting P Perineal pain after intact perineum
value; the between-study variance (τ2)estimated using restrict-
ed maximum likelihood was also reported. Meta-analysis of two cohort NRSs [38, 39] demonstrated that,
at day 2 (Fig. 2), the incidence of perineal pain in women with
an intact perineum following SVB was 42% (798 women;
Results 95% CI 0.56 to 0.75; I2 = 0%), whereas at 4–10 days post
birth (Fig. 3), the incidence of perineal pain with an intact
Eight RCTs and ten NRSs (nine cohort studies and one cross- perineum was 11% (789 women; 95% CI 0.09 to 0.13; I2 =
sectional survey study) from 11 countries were included 0%).
(Table 1) in the review, of which eight RCTs and eight The intensity of pain experienced by women with an intact
NRSs were included for quantitative synthesis by meta-anal- perineum following an SVB has only been reported by
ysis. No relevant systematic reviews were identified. Harrison et al. (1984) [39]. In a small study of 19 primiparous
In relation to the primary objective, 14 of the total of 18 women with an intact perineum following their first SVB, 12
studies (7 RCTs and 7 NRSs) which satisfied the inclusion (63%) women reported mild or moderate pain on the 1st day
criteria were undertaken to assess perineal pain after SVB postpartum. However, this decreased to 32% at day 2 and by
and 12 studies (6 RCTs and 6 NRSs) to assess dyspareunia the 4th day the intensity of pain was reported by only 5% of
after SVB. From all 18 of the included studies, a total of 3133 these women, as mild only.
women were followed up after SVB to assess perineal pain Meta-analysis of two studies [17, 38] (758 women; 95% CI
and 1567 women to assess dyspareunia. Data on perineal pain 0.01 to 100; I2 = 98%) demonstrated an incidence of perineal
were only available for meta-analysis on 2113 (67.4%) of the pain of 11% for women with an intact perineum following
3133 women from 12 studies. Data on dyspareunia were SVB at 3 months postpartum. However, the very high hetero-
available for meta-analysis on 1468 (97.7%) of the eligible geneity of this meta-analysis (I2 = 98%) and the very wide CI
1567 women from 9 studies. must be acknowledged.

Study quality and publication bias Perineal pain after first-degree perineal trauma

Quality assessment of the included studies revealed deficien- Albers et al. (1999) [38] reported the presence of perineal pain
cies in many methodological areas (Fig. S1). For the RCTs, for women with perineal trauma in the outer vagina and labia
two studies (25%) met all six quality criteria. One study as 64.3%, 25.5% and 5.5% at day 2, day 10 and 3 months,
Table 1 Study characteristics of all RCTs and NRSs included in the systematic review

Study characteristics of all RCTs included in the Systematic Review of Perineal pain and Dyspareunia (N = 8)
Author, country, language, Study design Population Intervention/study intention Number of women included at Outcomes
year, reference RCT: regarding perineal pain (PP) follow-up survey data with
Int Urogynecol J

Random sequence, allocation or dyspareunia (dysp) intact perineum and each

concealment, blinding for degree of perineal trauma
professionals-patients, blinding
outcomes assessment, enrolment
Cohort study:
data collection, enrolment
Almeida, Brazil, Spanish, RCT Primiparous and Compared two different suture PP: 61 women Perineal pain and use of
2008 [21] Random sequence: computer multiparous with techniques: all layers with Dysp: 23 women analgesia, wound
controlled; allocation 2nd-degree perineal continuous technique vs only healing and dyspareunia
concealment: table given by the trauma or episiotomy vagina with continuous
computer after SVB technique and interrupted
Blinding for professionals-patients: stitches in muscles and skin
did not report
Blinding outcomes assessment: the
same midwives do the repair and
postnatal assessment
Enrolment: consecutive
Aslam, Pakistan, English, RCT Primiparous with Compared two different suture 69 women in continuous Perineal pain
2015 [22] Random sequence: computer 2nd-degree perineal techniques: continuous technique group
controlled; allocation trauma or episiotomy technique vs interrupted
concealment: numbered, opaque after SVB stitches (do not mention if all
and closed envelopes layers. This group: not
Blinding for professionals-patients: included in the SR)
no comments were made
regarding technique during labour
or postnatal assessment
Blinding outcomes assessment: third
person blinded to treatment
allocation
Enrolment: consecutive
Beard, UK, English, 1974 RCT Nulliparous and Compared two different suture 100 women (Vicryl group) Perineal pain and use of
[35] Random sequence: not reported multiparous with materials: Vicryl st vs catgut analgesia
Allocation concealment: not episiotomy after SVB (catgut group not included)
reported Blinding for
professionals-patients: not
reported Blinding outcomes
assessment: not reported
Enrolment: unclear
Graczyk, Poland, Polish, RCT Primiparous with Compared two different suture PP: 65 women Perineal pain and
1998 [36] Random sequence: even and odd; episiotomy after SVB techniques: subcuticular (subcuticular group) dyspareunia
allocation concealment: even and continuous repair vs Dysp: 24 women
odd unspecified technique repair (subcuticular group)
Blinding for professionals-patients:
no; blinding outcomes
assessment: No
Enrolment: unreported
RCT Dysp: 153 women
Table 1 (continued)
McElhinney, UK, English, Random sequence: not reported; Primiparous and Compared two different suture Dyspareunia and perineal
2000 [23] allocation concealment: two sets multiparous with materials: Vicryl st vs Vicryl pain
of sealed envelopes second-degree perineal Rapid (PP: data unable to be
Blinding for professionals-patients: trauma or episiotomy included in MA)
not reported; blinding outcomes after SVB
assessment: not reported
Enrolment: not reported
Morano, Italy, English, RCT Primiparous with Compared two different suture PP: 214 women Perineal pain, use of
2006 [24] Random sequence: computer second-degree perineal techniques: all layers with Dysp: 214 women analgesia, wound
controlled; allocation trauma or episiotomy continuous technique vs healing and dyspareunia
concealment: even and odd in after SVB vagina with continuous
cards placed in an opaque technique and interrupted
envelope and sealed stitches in muscles and skin
Blinding for professionals-patients:
blinded; blinding outcomes
assessment: blinded
Enrolment: unreported
Perveen, Pakistan, English, RCT Primiparous and Compared two different suture PP: 100 women in Vicryl st Perineal pain, wound
2009 [37] Random sequence: alternating multiparous with materials and two different groups healing and dyspareunia
sequence in one of 4 groups; second-degree perineal suture techniques: Vicryl st vs Dysp: 100 women in Vicrylst
allocation concealment: no trauma or episiotomy catgut and all layers with groups
Blinding for professionals-patients: after SVB continuous technique vs only
no; blinding outcomes vagina with continuous
assessment: unclear technique, muscles and skin
Enrolment: unreported interrupted stitches
Catgut: not included
Valenzuela, Spain, Spanish, RCT Primiparous and Compared two different suture PP: 445 women Perineal pain and
2008 [25] Random sequence: computer multiparous with techniques: all layers with Dysp: 445 women dyspareunia
controlled; allocation numbered second-degree perineal continuous technique vs only
opaque and closed envelopes trauma or episiotomy vagina with continuous
Blinding for professionals-patients: after SVB technique and interrupted
blinded; blinding outcomes stitches in muscles and skin
assessment: blinded
Enrolment: unreported
Study characteristics of all NRSs included in the Systematic Review of Perineal Pain (PP) and Dyspareunia (Dysp) (N = 10)
Authors, country, language, Study design Population Intervention/study intention Number of women included at Outcomes
year, reference RCT: regarding perineal pain (PP) follow-up survey data with
Random sequence, allocation intact perineum and each
concealment, blinding for degree of perineal trauma
professionals-patients, blinding
outcomes assessment
Cohort:
data collection, enrolment
Albers, UK, English, 1999 Cohort study, prospective, Primiparous and Incidence of PP-related intact 792 intact perineum Perineal pain
[38] consecutive multiparous women, perineum and degree of 880 first degree (only outer
included in an RCT perineal trauma or episiotomy vagina and labial tear)
previously, having SVB First degree: could not be
in two different hospitals included because data were
grouped with 2nd degree
Int Urogynecol J
Table 1 (continued)
Second degree and episiotomy
not included: suture material
and method of repair not
Int Urogynecol J

reported
Harrison, Ireland, English, Cohort study, prospective, Primiparous women having Incidence of PP-related intact 19 women with intact perineum Perineal pain
1984 [39] consecutive SVB perineum and degree of Second degree and episiotomy
perineal trauma or episiotomy not included: catgut material
was used
Kalis, Czech Republic, Cohort study; prospective, Primiparous and Incidence of PP and PP: 51 women Perineal pain, dyspareunia
English, 2011 [40] non-consecutive multiparous women dysp-related episiotomy Dysp: 51 women and anal incontinence
having SVB with an
episiotomy at 60°
Klein, Canada, English, Cohort study; prospective, Primiparous and Incidence of PP and PP: 110 women with intact Perineal pain, dyspareunia
1994 [17] consecutive unclear multiparous women, dysp-related intact perineum perineum and pelvic floor strength
included in an RCT and degree of perineal trauma Dysp: 110 women with intact
previously, having SVB or episiotomy or perineum
3rd/4th-degree perineal injury Second degree and episiotomy
not included: suture material
and method not reported
3rd/4th-degree perineal injury
excluded from this SR
Layton, UK, English, 2004 Cross-sectional survey study, Primiparous after SVB Incidence of dysp-related intact 24 women with intact perineum Dyspareunia and urinary
[41] retrospective perineum and first- or Second degree not included: incontinence
second-degree perineal method not reported
trauma
Leeman, USA, English, Cohort study, prospective, Primiparous and Incidence of PP-related intact 89 women with intact perineum Perineal pain, use of
2007 [20] consecutive multiparous women, perineum and degree of Second degree not included: analgesia, anal
included in a RCT perineal trauma or episiotomy because not all of them had incontinence and urine
previously, having SVB or 3rd/4th-degree perineal been repaired incontinence
injury
McDonald, Australia, Cohort study, prospective, Primiparous women, Incidence of dysp-related intact 131 women intact perineum Dyspareunia and postnatal
English, 2015 [11] consecutive having birth perineum and degree of 1st and 2nd degree (grouped depression
perineal trauma or episiotomy sutured and unsutured
or 3rd/4th-degree perineal trauma) and episiotomy not
trauma included because no mention
material and technique repair
Persico, Italy, English, 2013 Cohort study, prospective, Primiparous and Incidence of PP and PP: 129 women intact perineum Perineal pain, use of
[18] consecutive multiparous women, dysp-related intact perineum Dysp: 123 women intact analgesia and
having birth and degree of perineal trauma perineum dyspareunia
or episiotomy Any degree of perineal trauma
or episiotomy not included
because IVD has been
included in same data
Safarinejad, Iran, English, Cohort study, prospective, Primiparous women, Incidence of dysp-related intact 169 women intact perineum Dyspareunia
2009 [19] consecutive having birth perineum and degree of No degree of perineal trauma or
perineal trauma or episiotomy episiotomy included because
IVD has been included and
material and technique repair
not mentioned
9 women intact perineum Perineal pain
Table 1 (continued)
Soares, Brazil, English, Cohort study, prospective, Primiparous and Incidence of PP-related intact Not included any degree of
2013 [42] consecutive multiparous women, perineum and degree of perineal trauma or episiotomy
having SVB perineal trauma or episiotomy because material and
technique repair not
mentioned

Study characteristics of all RCTs included in the Systematic Review of Perineal pain and Dyspareunia (N = 8)
Author, country, language, Was a validated measurement tool Study ‘data period’, timing of Extracted findings for perineal Extracted findings for perineal pain
year, reference used? Name (if given), setting, when survey(s) undertaken pain after SVB: incidence or dyspareunia after SVB:
mode of interview intensity of pain (total women %)
Use of analgesia
Almeida, Brazil, Spanish, PP: numerical rating scale (0–10): 2001–2002, at 1 h, day 4 and All continuous technique vs only Use of analgesia:
2008 [21] validated 6 weeks vagina continuous technique: All continuous technique vs only
Dysp: yes/no. Not validated PP: - at 1 h: 3 (10%) vs 3 (10%) vagina continuous tech:
Maternity ward and out-patient - at day 4: 15 (48%) vs 18 (60%) - at day 1: 18 (58%) vs 19 (63.3%)
clinic, verbal interview Dysp: - at 6 weeks: 5 (42%) vs 5 (45%) - at day 4: 9 (29%) vs 11 (36.6%)
- at 6 weeks: 11 (61%) vs 17 (56.6%)
Aslam, Pakistan, English, VAS: validated Study data period: not reported, All continuous technique: All continuous technique:
2015 [22] 1–3: mild, 4–10: moderate/severe at 24 h and day 10 - at 24 h: 31 (45%) - at 24 h:
Maternity ward and out-patient - at day 10: 12 (17%) mild: 26 (38%), moderate/severe: 5
clinic, verbal interview (7%)
- at day 10:
mild: 11 (16%), moderate/severe: 1
(1%)
Beard, UK, English, 1974 Pain severe, moderate, slight and Study data period: not reported, At day 1: 87 (87%) At day 1:
[35] none: not validated at day 1, day 2 and day 3 - at day 2: 77 (77%) slight: 40 (40%),
Maternity ward, verbal interview - at day 3: 64 (64%) moderate: 31 (31%) severe: 16(16%)
- at day 2:
slight: 43 (43%),
moderate: 27(27%), severe: 7(7%)
- at day 3:
slight: 54 (54%),
moderate: 10 (10%), severe: 0 (0%)
Use of analgesia:
Only subcuticular continuous tech:
- at day 1: 51 (51%)
- at day 2: 38 (38%)
- at day 3: 21 (21%)
Graczyk, Poland, Polish, 0–3: 0 no pain–3 worst pain. Not 1995, at day 3 and 2 months At least subcuticular continuous tech: At least subcuticular continuous tech:
1998 [36] validated. PP: - at day 3: 50 (77%) PP: - at day 3:
Maternity ward, verbal interview Dysp: - at 2 months: 3 (12%) 1: 18 (34.6%)
2: 25 (48%)
3: 6 (1.5%)
Dysp: - at 2 months:
1: 1(20%),
2: 1(20%)
3: 0 (0%)
McElhinney, UK, English, VAS: validated 1996, at 12 weeks Vicryl or Vicryl rapid:
2000 [23] Maternity ward, verbal interview - at 12 weeks: 20 (17%)
Int Urogynecol J
Table 1 (continued)
Morano, Italy, English, PP: VAS: validated 2003, at day 2 and day 10 All continuous techn vs only vagina cont tech: Use of analgesia:
2006 [24] Dysp: yes/no: not validated PP: - at day 2: 56 (52%) vs 89 (83%) All continuous tech vs only vagina
Self-administrated questionnaire and - at day 10: 32 (32%) vs 58 (60%) cont tech:
Int Urogynecol J

telephone Dysp: - at 3 months: 18 (21%) vs 18 (23%) - at day 2: 36 (33.6%) vs 58 (54.2%)

Perveen, Pakistan, English, PP: yes/no: not validated Study data period: not reported, All continuous technique vs only vagina
2009 [37] Dysp: yes/no: not validated at day 2, day 10 and 6 weeks continuous technique:
Setting: unreported, verbal interview PP: -at day 2: 9 (18%) vs 7 (14%)
at day 10: 4 (8%) vs 6 (12%)
at 6 weeks: 2 (4%) vs 3 (6%)
Dysp: at 3 months: 3 (6%) vs 3 (6%)
Valenzuela, Spain, Spanish, PP: analogous visual scale (0–10): 2005-2007, at day 2, day 10 and All continuous technique vs only vagina All continuous technique vs only
2008 [25] validated 6 weeks, at resuming continuous technique: vagina continuous technique:
No pain (0), slight pain (1–3) and intercourse and 3 months PP: - at day 2: 109 (49%) vs 113 (51%) - at day 2:
moderate/severe pain (4–10) - at day 10: 42 (19%) vs 41 (19%) slight: 80 (36%) vs 89(40%)
Dysp: yes/no. Not validated - at 6 weeks: 6 (3%) vs 4 (2%) moderate/severe: 29(13%) vs
Maternity ward and telephone, verbal Dysp: - Resuming intercourse: 109 (51%) 24(10%)
interview vs 110 (53%) - at day 10:
- At 3 months: 78 (36%) vs 76 (37%) slight: 37 (17%) vs 34 (15%)
moderate/severe: 5 (2%) vs 7(3%)
- at 3 months:
slight: 6 (2%) vs 4 (1%)
moderate/severe: 0 (0%) vs 0(0%)
Study characteristics of all NRSs included in the Systematic Review of Perineal Pain (PP) and Dyspareunia (Dysp) (N = 10)
Authors, country, language, Was a validated measurement tool Study ‘data period’, timing of Extracted findings for perineal pain and Extracted findings for perineal pain
year, reference used, name (if given)? when survey(s) undertaken dyspareunia after SVB: incidence and dyspareunia after SVB:
Setting (total women %) intensity of pain (total women %)
Albers, UK, English, 1999 Yes/no: no validated 1994–1996, at 2 days, 10 days Intact perineum:
[38] Setting: unreported, and 3 months PP:
self-administrated questionnaire. - at 2 days: 328 (41%)
- at 10 days: 83 (10%)
- at 3 months: 22 (3%)
First degree (only outer vagina or labial tear):
PP:
- at 2 days: 566 (64.3%)
- at 10 days: 222 (25.5%)
- at 3 months: 45 (5.5%)
Harrison, Ireland, English, Scale 0–4. Not validated July–August 1982, at day 1, day Intact perineum: Intact perineum:
1984 [39] Verbal interview, maternity ward 2, day 3, day 4 - at day 1: 12(63%) - at day 1:
- at day 2: 7 (37%) mild: 8(42%), moderate 4(21%),
- at day 3: 5 (26%) severe 0 (0%), very severe 0 (0%)
- at day 4: 2 (10%) - at day 2:
mild: 4(21%), moderate 2(11%),
severe 1 (5%), very severe 0 (0%)
- at day 3:
mild: 5(26%), moderate 0(0%),
severe 0 (0%), very severe 0 (0%)
- at day 4:
mild: 1(5%),
moderate 0(0%),
severe 0 (0%),
Table 1 (continued)
very severe 0 (0%)
Kalis, Czech Republic, PP: verbal rating score (0–3) 2008–2009, at 6 months Episiotomy:
English, 2011 [40] Validated PP: - at 6 months: 0 (0%),
Dysp: verbal rating score (0–3) dysp: at 6 months: 7 (14%)
Validated Out-patient clinic: Verbal
interview and telephone
Klein, Canada, English, PP: McGill Pain Scale 6-point scale 1988-1990; at 3 months Intact perineum: At 3 months: 17 women
1994 [17] ranging from 0 ‘no pain’ to 6 PP: - at 3 months: 33 (30%) (all interviewed women)
‘excruciating’. Validated Dysp: at resuming intercourses: 68 (67%) None-mild discomfort: 17
Dysp: 3-point scale. Not validated Distress-horrible/excruciating: 0
Out-patient clinic: verbal interview
Layton, UK, English, 2004 Yes/no: not validated 1992-1999; < 6 months after Intact perineum:
[41] Self-administrated questionnaire, SVB - up to 6 months: 8 (25%)
setting unreported Data not included in MA because did not mention
date: from resuming intercourse to 6 months
Leeman, USA, English, Visual analogue scale and present 2002–2005; at 6 months Intact perineum:
2007 [20] pain intensity - at discharge: not reported
Validated - at 6 weeks–3 months: 8 (9%)
Out-patient clinic: verbal interview Not included in MA because did not mention day
and telephone of discharge and data provided were for a period
of time: from 6 weeks to 3 months
McDonald, Australia, Postnatal sexual health. Not 2003–2005, from 6 different Intact perineum:
English, 2015 [11] validated hospitals, at 3 months, - at 6 months: 44 weeks (33.6%)
Australian longitudinal women’s 6 months, 12 months and - at 12 months: 30 weeks (22.7%)
health study 18 months
Validated
Self-administrated questionnaire,
unreported
Persico, Italy, English, 2013 PP: VNS (0–10) and VRS (none, 2009–2010, at day 1, Intact perineum: At day 1:
[18] mild, moderate, strong, very day 7 and 6 months PP: - at day 1: 93(72%) - resting: 89 (69%) none or mild
strong). Validated - at 6 months: 1(0.8%) - sitting: 116 (90%) none or mild
Dysp: VNS (0–10) and VRS (none, Dysp: - at 7 weeks: 20 (25.6%) - moving: 104(81%) none or mild
mild, moderate, strong, very - at 6 months: 6 (4.9%) Use of analgesia: intact perineum:
strong). Validated - at day 1: 33.3%
Maternity ward and telephone: - at day 7: 4.8%
verbal interview
Safarinejad, Iran, English, Female Sexual Function Index 2005–2006, at resuming Intact perineum: Intact perineum:
2009 [19] (FSFI) intercourse, 6 months and - at resuming intercourse: 107(63.3%) None or mild pain:
Validated 12 months - at 3 months: 47 (27.8%) - at 3 months: 143 (84.6%)
Setting: not reported, verbal - at 6 months: 31 (18.3%) - at 6 months: 154 (91%)
interview - at 12 months: 19 (11.2%) - at 12 months: 159 (94%)
Soares, Brazil, English, Numerical pain scale, pain-related 2010–2011, at day 1 and Intact perineum:
2013 [42] self-statements Scale 8 weeks - at day 1: 6 (67%)
Catastrophising subscale - at 8 weeks: 0 (0%)
Validated
Maternity ward and telephone:
verbal interview
Int Urogynecol J
Int Urogynecol J

Fig. 2 Intact perineum. Perineal

pain at day 2

respectively. However, although this was a large study of 5471 decreasing to only 1% at day 10. Similarly, in the cohort of
primiparous and multiparous women, the authors chose to 216 primiparous and multiparous women in the study by
include only labial tears and lower vaginal trauma into a Valenzuela et al. (2009) [25], 13% at day 2 and 2% at day
sub-group of ‘first-degree perineal trauma’ and all ‘other types 10 felt moderate or severe pain.
of first-degree perineal trauma’ were grouped and analysed From all of the studies included in this systematic review,
with any second-degree perineal trauma. there were not enough extracted data suitable to undertake a
meta-analysis for perineal pain at 6 weeks, 3 or 6 months.

Perineal pain after 2nd-degree perineal trauma or episiotomy

repaired with the continuous technique and absorbable Perineal pain after the second perineal trauma or episiotomy
material where only the vaginal tissue was repaired
with the continuous technique
Meta-analysis of three studies [24, 25, 37] showed an inci-
dence of perineal pain at day 2 postpartum of 39% (379 wom- Meta-analysis of three studies [24, 25, 37] showed an inci-
en; 95% CI 0.21 to 0.70; I2 = 78%) for women with a second- dence of perineal pain for women with a second-degree tear
degree tear or episiotomy following SVB with all layers of or episiotomy following SVB with only the vaginal mucosa
trauma sutured by the continuous technique. A further meta- sutured by the continuous technique of 41% (378 women;
analysis of five studies [21, 22, 24, 25, 37] showed that at day 95% CI 0.15 to 1.0; I2 = 93%) at 2 days postpartum. A further
4–10 postpartum, the incidence of perineal pain had reduced meta-analysis of four studies [21, 24, 25, 37] showed that at 4–
to 23% (465 women; 95% CI 0.14 to 0.38; I 2 = 78%). 10 days the postpartum rate of perineal pain was 31% (393
However, the I2 values for both of these meta-analyses was women; 95% CI 0.14 to 0.68%; I2 = 93%). Because of the
78%, showing high heterogeneity. considerable methodological differences between Perveen
Unlike all of the other studies included in the two meta- et al. [37] and the other studies [21, 24, 25], the meta-
analyses, Perveen et al. (2009) [37] did not use a validated analysis was repeated with the exclusion of this study.
questionnaire in their study and the total score for study qual- Despite the fact that the rate of perineal pain observed at both
ity assessment was very low. Repeat meta-analyses were per- day 2 and 4–10 days postpartum was higher than previously,
formed with this study excluded that showed a higher rate of 65% (329 women; 95% CI 0.40 to 1.0; I2 = 92%) and 41%
perineal pain at day 2 postpartum of 50% (329 women; 95% (343 women; 95% CI 0.19 to 0.87; I2 = 94%), respectively, the
CI 0.43 to 0.58; I2 = 0%) (Fig. 4) and a slightly higher rate of heterogeneity still remained very high.
perineal pain at 4–10 days postpartum of 27% (415 women;
95% CI 0.17 to 0.42; I2 = 77%) (Fig. 5). However, the I2 value
for 4–10 days postpartum remained high. Perineal pain after episiotomy when subcutaneous tissue was
Regarding the intensity of pain for women with a second- repaired with the continuous technique
degree tear or episiotomy following SVB with all layers of
trauma sutured by the continuous technique, Aslam et al. Meta-analysis of two RCTs [35, 36], showed an incidence of
(2015) [22] reported that 7% of the cohort of 69 primiparous perineal pain of 69% (165 women; 95% CI 0.58 to 0.83; I2 =
women showed moderate or severe perineal pain at day 2, 0%) at 3 days postpartum for women who had episiotomy

Fig. 3 Intact perineum. Perineal

pain at 4–10 days
 Int Urogynecol J

Fig. 4 Second-degree perineal

trauma or episiotomy repaired
with the continuous technique
throughout all layers. Perineal
pain at day 2, excluding Perveen

during SVB and at least subcutaneous tissue was sutured with Dyspareunia after first-degree perineal trauma
the continuous technique (Fig. 6).
Regarding pain intensity, the cohort of 200 primiparous No studies that met the inclusion criteria for SR reported the
and multiparous women in the study by Beard et al. (1974) incidence of dyspareunia following first-degree perineal trau-
[35] stated that moderate pain was reported by 10% at day 3, ma at the time of SVB.
whereas in a cohort of 117 primiparous women in the study by
Graczyk et al. (1998) [36], 49.5% reported that the perineal
pain was moderate or severe. Dyspareunia after second-degree perineal trauma
or episiotomy repaired with the continuous technique
and absorbable material
Dyspareunia after SVB
There were not enough data suitable for meta-analysis of the
Dyspareunia after intact perineum incidence of dyspareunia at resuming intercourse. In a study
by Valenzuela et al. (2009) [25] of 198 mixed parity women,
Meta-analysis of two studies [17, 19] showed an incidence 109 (55%) acknowledged dyspareunia the first time they re-
of reported dyspareunia upon resumption of sexual inter- sumed intercourse.
course following SVB with an intact perineum of 65% Meta-analysis of two studies [21, 37] showed an incidence
(270 women; CI 0.56 to 0.75; I2 = 0%) (Fig. 7). Three stud- of dyspareunia for women with a second-degree tear or episi-
ies [11, 18, 19] provided data on dyspareunia for women otomy following SVB with all layers of trauma sutured by the
with an intact perineum following SVB at 6 months post- continuous technique of 16% (95% CI 0.02 to 1.0; I2 = 86%)
partum and meta-analysis of these gave a rate of 15% (423 at 6–7 weeks postpartum. However, the high I2 value is prob-
women; 95% CI 0.05 to 0.44; I2 = 91%). Two of the studies ably due to the very small number of women (n = 62) and low-
[11, 19] included in this meta-analysis involved women quality assessment scores of the included studies, so this find-
who had undergone their first SVB. However, the study ing must be interpreted with caution.
by Persico et al. (2013) [18] used a cohort of 123 nullipa- Regarding longer term dyspareunia, meta-analysis of three
rous and multiparous women. The meta-analysis was there- studies [23–25] demonstrated an incidence of 19% (434 wom-
fore re-run with Persico et al. (2013) excluded and showed a en; 95% CI 0.13 to 0.28%; I2 = 63%) for dyspareunia at
slightly higher incidence of 25% but not much improve- 3 months postpartum. The study by McElhinney et al.
ment in I2 (0.14 to 0.45; I2 = 85%). Interestingly, the pres- (2000) had a much lower quality score, which may have con-
ence of dyspareunia for women with an intact perineum tributed to the moderate I2 value of 63%. The meta-analysis
following SVB remained similar at 12 months postpartum, was redone with this study excluded; the rate of dyspareunia
with data pooled from two studies [11, 19] showing an for women with a second-degree tear or episiotomy following
incidence of 16% (301 women; 95% CI 0.08 to 0.32; I2 = SVB with all layers of trauma sutured by the continuous tech-
83%) (Fig. 8). However, the high heterogeneity among nique was slightly higher at 23% (281 women; 95% CI 0.18 to
these studies must be considered. 0.30; I2 = 0%), with improved homogeneity (Fig. 9).

Fig. 5 Second-degree perineal

trauma or episiotomy repaired
with the continuous technique
throughout all layers. Perineal
pain at day 4–10 days, excluding
Perveen
Int Urogynecol J

Fig. 6 Episiotomy repaired with

the continuous technique at least
in the subcuticular tissue. Perineal
pain at 3 days

The incidence of dyspareunia at 6 months postpartum was of pain is similar to that reported by the women who sustained
only reported in one study where Kalis et al. (2011) [40], in a perineal trauma, it is more likely for pain to be reported for
small study of 51 nulliparous women with episiotomy and longer in case of a second-degree tear or episiotomy. Women
continuous repair technique to all layers, reported an incidence with an episiotomy reported the highest rate of perineal pain
of 14%. after SVB compared with other degrees of perineal trauma.
However, the incidence is lower when a continuous repair
Dyspareunia after second-degree perineal trauma technique has been used. The intensity of perineal pain and
or episiotomy where only the vaginal tissue was repaired use of analgesia in the postpartum period were not always
with the continuous technique adequately reported in the included studies limiting our ability
to understand the natural history of this symptom.
There were not enough data suitable for meta-analysing the Dyspareunia is frequently reported by women following
incidence of dyspareunia at resuming intercourse for this SVB, even without perineal trauma, and sometimes this per-
group. However, in the study by Valenzuela et al. (2009), sists into the longer term. Our metanalysis has also shown that
59% of women (110/186) with either a second-degree tear or dyspareunia is frequently experienced by women following a
episiotomy following SVB with only the vagina mucosa second-degree perineal tear or episiotomy at the time of SVB.
repaired using the continuous technique reported dyspareunia However, this seems to be less likely to be reported if the
the first time they resumed sexual intercourse. At 3 months trauma has been repaired with the continuous technique for
postpartum, a meta-analysis of two RCTs [24, 25] showed an all layers compared with when the vaginal epithelium is the
incidence of 28% (263 women; 95% CI 0.22 to 0.35; I2 = 0%) only layer repaired using this technique. Due to confounding
for women with a second-degree tear or episiotomy following factor of the hypoestrogenic state when breastfeeding on post-
SVB with only the vaginal mucosa repaired using a continu- natal dyspareunia, we attempted to extract data on
ous suture technique. breastfeeding and lubrication disorders. Safarinejad et al.
(2009) [19] was the only study that reported data on both
Dyspareunia after episiotomy where the skin was closed aspects. Although lubrication disorders were reported at 3, 6
using a subcutaneous continuous technique and 12 months postpartum, being slightly higher with episiot-
omy, the study did not find any correlation between
The incidence and intensity of dyspareunia were only reported dyspareunia and perineal trauma for women who were
in one small cohort study by Graczyk et al. (1998) [36] who breastfeeding.
found 12% (3/24) of the women reported pain as mild or Several published studies have reported relatively high
moderate during sexual intercourse at 2 months postpartum. rates of pre-conception dyspareunia or dyspareunia after un-
dergoing an elective caesarean section [11, 43, 44]. It is there-
fore plausible that, for some women, postnatal dyspareunia
Discussion represents a persistence of a problem that preceded the birth.
Nevertheless, our findings highlight the importance of giving
Regarding perineal pain, meta-analysis demonstrated that attention to this symptom even in women who did not sustain
women with no perineal trauma still reported pain at 2 days, any degree of trauma and the need for further research into the
10 days and 3 months postpartum. Although at 2 days the rate aetiology and natural history of dyspareunia.

Fig. 7 Intact perineum.

Dyspareunia at resuming
intercourse
 Int Urogynecol J

Fig. 8 Intact perineum.

Dyspareunia at 12 months
postpartum

Vaginal childbirth is generally accepted as a main risk fac- report [47] highlights the term ‘perineum’ is often used in
tor for pelvic floor dysfunction, especially when the levator different ways. Within maternity care it is often used in its
ani muscle (LAM) has been damaged [45]. One of our initial most restricted sense, equating to the perineal body [16], while
aims was to extract data on perineal pain and dyspareunia anatomists refer to it in its widest sense to include all the
when an injury on LAM occurred during the SVB. structures within the urogenital and anal triangles [7]. We
However, none of the included studies reported on LAM believe that the anatomical definition of the perineum is more
injuries. inclusive and hence should be standardised and adopted by all
disciplines. Additionally, although studies tended to follow
the classification of trauma as proposed in the NICE Clinical
Strengths and weaknesses Guidelines [48], authors of these studies did not always report
results categorised by each degree of trauma and opted to
The main strength of this systematic review lies in its meth- present in other categories, for example, whether the trauma
odological aspects, namely, a rigorous search strategy as well was sutured or not. Finally, some of the authors [49, 50] sug-
as the study selection, quality appraisal and data extraction by gest that second-degree tears vary in depth and complexity
independent reviewers and analysis following standardised and hence require some form of sub-categorisation or re-
protocols. The terms ‘anal sphincter’ or ‘OASIS’ or ‘instru- grouping to improve our understanding of trauma in relation
mental vaginal birth’ were not included in the search to reduce to perineal pain and dyspareunia after birth. However, until
the risk of limiting access to all possible relevant articles. We such a sub-classification is clearly defined and standardised,
also searched the literature irrespective of study design and outcomes related to this degree of trauma should be reported
hence were able to include data from both randomised or under the relevant category and not combined with first-
non-randomised studies. However, we appreciate that the degree tears or OASIs depending on whether they are deemed
main limitation of our review arises from the quality and the superficial or deep respectively.
heterogeneity of included primary studies. Of a total of 266
potentially eligible papers, 103 studies (41.5%) were not in-
cluded because the suture material and/or method of repair Conclusion and implications
had not been reported. However, a decision to exclude such
studies was made a priori in view of the strong confounding This systematic review highlights the current gap in our un-
effect of the methods and materials used for the repair on our derstanding about the size and, consequently, the potential
primary outcomes of interest [13, 14, 46]. Moreover, the rel- impact of perineal pain and dyspareunia following childbirth
atively short follow-up periods, insufficient information on on women’s health. Maternity-related healthcare professionals
pain intensity, variability in measurement tools and time must appreciate that such morbidities are not only limited to
points and small sample size of some studies were, at times, women who experience perineal trauma. Further studies on
a limitation to our analyses. Nevertheless, we were still able to the incidence of both perineal pain and dyspareunia related to
achieve the primary aims of the review. One of the main issues intact perineum and perineal trauma after SVB are needed
that our review has identified and, sometimes, limited our with particular attention to exploring the severity of these
analysis was the inconsistency in the definition of the symptoms, use of analgesia and impact on the quality of life
Bperineum^ among studies. The ‘Terminologia Anatomica’ of the woman and her family at the short and longer term.

Fig. 9 Second-degree perineal

trauma or episiotomy repaired
with the continuous technique
throughout all layers.
Dyspareunia at 3 months,
excluding McElhinney
Int Urogynecol J

Although not one of our initial aims, it became apparent 15. Standring S. Gray’s anatomy: the anatomical basis of clinical prac-
tice. 41st ed. London: Elsiever; 2016. 1562 p
that the definition of Bthe perineum^ requires clarification and
16. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B,
standardisation. Lee J, et al. An International Urogynecological Association
(IUGA)/International Continence Society (ICS) joint report on the
Compliance with ethical standards terminology for female pelvic floor dysfunction. Int Urogynecol J.
2010;21(1):5–26.
17. Klein M, Gauthier RJ, Robbins JM, Kaczorowski J, Waghorn K,
Conflicts of interest None.
Gelfand M, et al. Relationship of episiotomy to perineal trauma and
morbidity, sexual dysfunction, and pelvic floor relaxation. Am J
Publisher’s note Springer Nature remains neutral with regard to jurisdic- Obstet Gynecol. 1994;171(3):591–8.
tional claims in published maps and institutional affiliations. 18. Persico G, Vergani P, Cestaro C, Grandolfo M. Assessment of post-
partum perineal pain after vaginal delivery: prevalence, severity and
determinants. A prospective observational study. Minerva Ginecol.
References 2013;65(6):669–78.
19. Safarinejad M, Kolahi A, Hosseini L. The effect of the mode of
delivery on the quality of life, sexual function, and sexual satisfac-
1. Estadística IneIN. Estadística de nacimientos. Movimiento natural
tion in primiparous women and their husbands. J Sex Med.
de la población [Internet]. [cited 2018 Jun 5]. Available from: http://
2009;6(6):1645–67.
www.ine.es/dyngs/INEbase/es/categoria.htm?c=Estadistica_
20. Leeman L, Rogers R, Greulich B, Albers L. Do unsutured second-
P&cid=1254735573002
degree perineal lacerations affect postpartum functional outcomes?
2. Statista: the statistics portal. Vaginal and C-section deliveries in US
J Am Board Fam Med. 2007;20(5):451–7.
2013 by risk | Statistic [Internet]. Hamburg: Statista. 2016 [cited
21. de Almeida SFS, Gonzalez Riesco ML. Randomized controlled
2018 Jun 5]. Available from: https://www.statista.com/statistics/
clinical trial on two perineal trauma suture techniques in normal
633106/rate-of-total-deliveries-in-us-by-risk-level-and-delivery-
delivery. Rev Lat Am Enfermagem. 2008;16(2):272–9.
type/
22. Aslam R, Khan SA, Amir ZU, Amir F. Interrupted versus continu-
3. National Health System. NHS Digital. NHS Maternity Statistics,
ous sutures for repair of episiotomy or 2nd degree perineal tears. J
England 2016-17 [Internet]. London. 2017 [cited 2018 Jun 5].
Ayub Med Coll JAMC. 2015;27(3):680–3.
Available from: https://digital.nhs.uk/data-and-information/
publications/statistical/nhs-maternity-statistics/2016-17 23. McElhinney B, Glenn D, Dornan G, Harper M. Episiotomy repair:
Vicryl versus Vicryl rapide. Ulster Med J. 2000;69(1):27–9.
4. Observatorio de salud de las mujeres. Informe sobre la Atención al
Parto y Nacimiento en el Sistema Nacional de Salud. Estrategia de 24. Morano S, Mistrangelo E, Pastorino D, Lijoi D, Costantini S, Ragni
atención al parto normal en el Sistema Nacional de Salud. N. A randomized comparison of suturing techniques for episiotomy
[Internet]. 2015 [cited 2018 Jul 31]. Available from: https://www. and laceration repair after spontaneous vaginal birth. J Minim
m s s s i . g o b . e s / o rg a n i z a c i o n / s n s / p l a n C a l i d a d S N S / p d f / Invasive Gynecol. 2006;13(5):457–62.
InformeFinalEAPN_revision8marzo2015.pdf 25. Valenzuela P, Saiz Puente MS, Valero JL, Azorin R, Ortega R,
5. Petz B. Birth & Death Rates | Ecology Global Network [Internet]. Guijarro R. Continuous versus interrupted sutures for repair of epi-
Ecology Communications Group, Inc. (ECG). 2010 [cited 2018 siotomy or second-degree perineal tears: a randomised controlled
Aug 1]. Available from: http://www.ecology.com/birth-death-rates/ trial. BJOG. 2009;116(3):436–41.
6. Woolhouse H, Gartland D, Perlen S, Donath S, Brown SJ. Physical 26. OSTEBA. Clinical Practice Guideline on Care in Normal
health after childbirth and maternal depression in the first 12 Childbirth. Quality Plan for the Spanish National Healthcare
months post partum: results of an Australian nulliparous pregnancy System of the Spanish Ministry for Health and Social Policy. 2010.
cohort study. Midwifery. 2014;30(3):378–84. 27. Intrapartum care for healthy women and babies | Guidance and
7. Webb SS, Sherburn M, Ismail KMK. Managing perineal trauma guidelines | NICE. RCOG. NICE. 2014.
after childbirth. BMJ. 2014;349:g6829. 28. Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman
8. Macarthur AJ, Macarthur C. Incidence, severity, and determinants AD, et al. The Cochrane Collaboration’s tool for assessing risk of
of perineal pain after vaginal delivery: a prospective cohort study. bias in randomised trials. BMJ. 2011;343:d5928.
Am J Obstet Gynecol. 2004;191(4):1199–204. 29. Munn Z, Moola S, Riitano D, Lisy K. The development of a critical
9. Olsson A, Lundqvist M, Faxelid E, Nissen E. Women’s thoughts appraisal tool for use in systematic reviews addressing questions of
about sexual life after childbirth: focus group discussions with prevalence. Int J Heal Policy Manag. 2014;3(3):123–8.
women after childbirth. Scand J Caring Sci. 2005;19(4):381–7. 30. Team RC. R: A language and environment for statistical comput-
10. O’Malley D, Higgins A, Smith V. Postpartum sexual health: a ing. R Foundation for Statistical Computing, Vienna, Austria. 2013.
principle-based concept analysis. J Adv Nurs. 2015;71(10):2247– 31. Schwarzer G. Meta: an R package for meta-analysis. R News.
57. 2007;7(3):40–5.
11. McDonald E, Gartland D, Small R, Brown S. Dyspareunia and 32. Viechtbauer W. Conducting Meta-analyses in R with the metafor
childbirth: a prospective cohort study. BJOG An Int J Obstet package. J Stat Softw. 2010;36(3):1–48.
Gynaecol. 2015;122(5):672–9. 33. Higgins J, Thompson S. Quantifying heterogeneity in a meta-anal-
12. De Souza A, Dwyer PL, Charity M, Thomas E, Ferreira CHJ. The ysis. Wiley Online Libr. 2002;21:1539–58.
effects of mode delivery on postpartum sexual function: a prospec- 34. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring
tive study. BJOG An Int J Obstet Gynaecol. 2015;122(10):1410–8. inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60.
13. Kettle C, Dowswell T, Ismail KMK. Absorbable suture materials 35. Beard R, Boyd I, Sims C. A trial of polyglycolic acid and chromic
for primary repair of episiotomy and second-degree tears. Cochrane catgut sutures in episiotomy repair. Br J Clin Pract. 1974;28(12):
Database Syst Rev. 2010;6. 409–10.
14. Kettle C, Dowswell T, Ismail KM. Continuous and interrupted su- 36. Graczyk S, Limanowski M, Wyduba M. Suture of the episiotomy
turing techniques for repair of episiotomy or second-degree tears. wound: comparison of two techniques from clinical and cosmetic
Cochrane Libr. 2012;11. aspects. Ginekol Pol. 1998;69(1):6–11.
 Int Urogynecol J

37. Perveen F, Shabbir T. Perineal repair: comparison of suture mate- 45. Dietz HP. Pelvic floor trauma in childbirth. Aust New Zeal J Obstet
rials and suturing techniques. J Surg Pakistan. 2009;14(1). Gynaecol. 2013;53(3):220–30.
38. Albers L, Garcia J, Renfrew M, McCandlish R, Elbourne D. 46. Kettle C, Hills RK, Jones P, Darby L, Gray R, Johanson R.
Distribution of genital tract trauma in childbirth and related postna- Continuous versus interrupted perineal repair with standard or rap-
tal pain. Birth. 1999;26(1):11–7. idly absorbed sutures after spontaneous vaginal birth: a randomised
39. Harrison R, Brennan M, North P, Reed J, Wickham E. Is routine controlled trial. Lancet. 2002;359(9325):2217–23.
episiotomy necessary? Br Med J. 1984;288:1971–5. 47. Federative Committee on Anatomical Terminology. Terminologia
40. Kalis V, Landsmanova J, Bednarova B, Karbanova J, Laine K, anatomica [Internet]. 1998 [cited 2018 Oct 11]. p. A09.5.00.001
Rokyta Z. Evaluation of the incision angle of mediolateral episiot- Entity Page. Available from: https://www.unifr.ch/ifaa/Public/
omy at 60 degrees. Int J Gynecol Obstet. 2011;112(3):220–4. EntryPage/TA98 Tree/Entity TA98 EN/09.5.00.001 Entity TA98
41. Layton S. The effect of perineal trauma on women’s health. Br J EN.htm.
Midwifery. 2004;12(4):231–6 6p. 48. National Institute for Health and Care Excellence. Intrapartum care
42. Soares A, Couceiro T, Cavalcanti Lima L, Lago Flores F, for healthy women and babies. (Clinical Guideline No 190). NICE;
Alcoforado E, Couceiro Filho R. Association of pain 2014. Available from: https://www.nice.org.uk/guidance/cg190
catastrophizing with the incidence and severity of acute and persis- 49. Leeman L, Fullilove A, Borders N, Manocchio R, Albers L, Rogers
tent perineal pain after natural childbirth: longitudinal cohort study. R. Postpartum perineal pain in a low episiotomy setting: association
Brazilian J Anesthesiol. 2013;63(4):317–21. with severity of genital trauma, labor care, and birth variables.
43. O’Malley D, Higgins A, Begley C, Daly D, Smith V. Prevalence of Birth. 2009;36(4):283–8.
and risk factors associated with sexual health issues in primiparous
50. Leeman L, Rogers R, Borders N, Teaf D, Qualls C. The effect of
women at 6 and 12 months postpartum; a longitudinal prospective
perineal lacerations on pelvic floor function and anatomy at 6
cohort study (the MAMMI study). BMC Pregnancy Childbirth.
months postpartum in a prospective cohort of nulliparous women.
2018;18(1):196.
Birth. 2016;43(4):293–302.
44. Durnea CM, Khashan AS, Kenny LC, Tabirca SS, O’Reilly BA. An
insight into pelvic floor status in nulliparous women. Int
Urogynecol J. 2014;25(3):337–45.