Exploring the Link Between Vaginal Delivery and Postpartum Dyspareunia: An Observational Study

Abstract

Background/Objective: Dyspareunia negatively affects women’s lives. Up to 35% suffer from postpartum dyspareunia. Many factors may influence the occurrence of postpartum dyspareunia, but little is known about them. This study aimed to look at the frequency of dyspareunia one year postpartum in a cohort of primiparae. Which perinatal factors influence the frequency of postpartum dyspareunia? Methods: A total of 3264 primiparae were included in this observational cohort study. Perinatal factors were documented, and a specially designed questionnaire was sent to them one year postpartum. The primary outcome was the frequency of dyspareunia one year postpartum. The secondary outcomes included potential influencing factors such as birthing method (spontaneous bed delivery, spontaneous delivery other than bed, water delivery, and vacuum-assisted delivery); perineal injuries (first- and second-degree perineal tears, obstetric anal sphincter injuries (OASIs), and episiotomies); and the use of oxytocin. Results: Postpartum dyspareunia was observed in 15% of the 3264 primiparae. In multivariate analysis, there were influences found in the perineal injury group, especially for first- and second-degree perineal tears and OASIs. In the oxytocin group, a trend toward a higher rate of postpartum dyspareunia was observed. No influence of the different birthing methods was found. Conclusions: Postpartum dyspareunia, affecting 15% of women one year after vaginal delivery, is associated with perineal injuries, particularly minor perineal tears and OASIs. This highlights the importance of good preparation of the perineum and pelvic floor before delivery, efficient perineal protection during labor, and the use of a precise repair technique for all perineal injuries.

1. Introduction

Dyspareunia is classified as a subtype of chronic pelvic pain and is defined as the complaint of persistent or recurrent pain or discomfort associated with attempted or complete vaginal penetration [1]. It may be further differentiated into superficial dyspareunia, typically localized to the vulva or vaginal introitus, and deep dyspareunia, which is experienced during deeper penetration and frequently associated with pelvic pathology.

Chronic pelvic pain is characterized by pain persisting for a minimum duration of six months. Together with dysmenorrhea and noncyclical pelvic pain, dyspareunia constitutes a core component of chronic pelvic pain syndrome [2]. Chronic pelvic pain syndrome is associated not only with physical morbidity but also with negative cognitive, behavioral, sexual, and emotional consequences, as well as with symptoms and signs related to lower urinary tract, sexual, bowel, pelvic floor, or gynecological dysfunction.

The etiology of dyspareunia is heterogeneous, necessitating a comprehensive and differentiated diagnostic approach [3]. In gynecological practice, infectious causes represent a frequent category and, once diagnosed, may be managed effectively with targeted treatment. In addition, a range of non-infectious pathologies can result in dyspareunia, as lichen sclerosus, vulvodynia, chronic bladder pain syndrome/interstitial cystitis, Genitourinary Syndrome of Menopause (GSM), and endometriosis. Pelvic floor disorders such as urinary and fecal incontinence and prolapse are another relevant contributor to dyspareunia. Dyspareunia may also arise as a sequela of surgical interventions or radiotherapy often due to scarring or fibrosis.

Beyond these biomedical determinants, the biopsychosocial model provides a critical framework for understanding dyspareunia in general and postpartum dyspareunia in particular [4,5,6]. Pain is not solely explained by anatomical injury but may be maintained by central sensitization, maladaptive coping strategies, and interpersonal or sexual dysfunction. Psychological comorbidities such as anxiety and depression lower pain thresholds and sexual desire, thereby exacerbating dyspareunia. Social and relational factors, including couple communication and cultural attitudes toward sexuality, further influence the experience of pain.

Postpartum dyspareunia is a clinically relevant condition, with prevalence rates reported to be as high as 35% within the first year after delivery [7,8].

Compared to cesarean section, vaginal delivery is a well-known risk factor for postpartum dyspareunia. According to a recent systematic review, the prevalence of postpartum dyspareunia six to twelve months after delivery is 42% (95% CI, 31–56%) following vaginal delivery, 37% (95% CI, 28–46%) following instrumental delivery, and 26% (95% CI, 19–34%) following cesarean section [9].

Vaginal delivery might be associated with perineal trauma including episiotomy, first- and second-degree tears, and severe third- and fourth-degree perineal tears, called obstetric anal sphincter injuries (OASIs). These injuries are well-documented risk factors for postpartum dyspareunia [10]. A register-based cohort study reported a prevalence of mild-to-moderate postpartum dyspareunia of 30.0% following second-degree perineal tears and 29.1% following episiotomy. Severe or unbearable postpartum dyspareunia was reported by 2.4% of women with a second-degree tear and 3.8% of women with an episiotomy [11].

Other potential influencing factors are breastfeeding, psychosocial factors and pre-existing psychiatric disorders, and dyspareunia [3,12].

Breastfeeding is likely associated with increased postpartum dyspareunia due to reduced levels of estrogen, progesterone, and testosterone, which result in vaginal dryness, decreased elasticity, thinning of the mucosa, and diminished arousal, all of which predispose to painful intercourse [13].

While instrumental delivery and perineal injuries are more likely to provoke superficial postpartum dyspareunia, estrogen deficiency and cesarean sections are more often associated with deep postpartum dyspareunia [3,14,15,16].

Postpartum dyspareunia is known to decrease within the first year postpartum. A systematic review showed a prevalence of 42% (95% CI, 26–60%) at 2 months, 43% (95% CI, 36–50%) at 2–6 months, and 22% (95% CI, 15–29%) at 6–12 months postpartum [7]. The usual postpartum care often ends after six to twelve weeks postpartum. Still, one in five women continues to suffer from postpartum dyspareunia one year later. This underscores the need for long-term postpartum surveillance and care.

Despite its frequency, the specific perinatal risk factors contributing to its development remain incompletely understood and are discussed with considerable controversy. Factors under investigation include the mode of vaginal delivery, the degree and management of perineal trauma, and the intrapartum use of oxytocin [10,17,18].

The impact of postpartum dyspareunia extends beyond physical health, exerting deleterious effects on intimate relationships, sexual functioning, and overall quality of life. Importantly, postpartum dyspareunia constitutes one of the frequently neglected long-term sequelae of childbirth [17,19,20]. Still, most women do not discuss sexual disfunction with their health care providers but are willing to answer when asked [21,22,23]. This underscores the importance of assessing postpartum dyspareunia not only within the first six to twelve weeks postpartum but also up to one year or longer.

The aim of the present study was to investigate the frequency of postpartum dyspareunia one year postpartum in a cohort of primiparae. Particular emphasis was placed on evaluating potential perinatal influencing factors, including (1) different vaginal birthing methods, (2) perineal injuries, and (3) the use of oxytocin during labor. A better understanding of these associations may facilitate the development of preventive strategies, inform clinical practice in perinatal care, and ultimately contribute to the reduction in postpartum dyspareunia and its associated burden.

2. Materials and Methods

2.1. Study Design

The data originate from an obstetric register from 1991 to 2006 in the Department of Obstetrics and Gynecology of a Swiss teaching hospital. The main reason for the database was to collect perinatal data of different birthing methods to assess the safety of mother and child. Objective and subjective data, such as peri- and postnatal maternal parameters, were collected using questionnaires that included a cover letter stating that the intention was to store the data and analyze them anonymously. The questionnaires were given to the women during pregnancy and delivery, within a week postpartum and one year postpartum (sent by post). Between 1991 and 2006, every woman pre-registered for birth got to answer the questionnaire. Roughly 18,000 questionnaires were distributed, out of which more than 17,000 datasets resulted. About 9000 patients answered the self-reported questionnaire one year postpartum. The questionnaire was sent by post and took 5–10 min to fill in. It was sent 12 months (+/− 2 weeks) postpartum to the women.

In accordance with common practice during that period, no additional separate written informed consent was obtained. The use of the cover letter and questionnaire for data evaluation and publication was approved by the responsible ethics committee.

2.2. Standards of Labor Management

The Swiss standards of care for deliveries in teaching hospitals have remained comparable between 1991 and 2025. They include external fetal heart rate monitoring, intermittent monitoring in the first stage of labor, continuous monitoring in the second stage of labor, oxytocin infusion if the first or second stage of labor is prolonged or if the number of contractions is insufficient in the second stage of labor (less than 4–5 contractions per 10 min). Restrictive use of episiotomy and perineal protection through the manual perineal protection technique are well-established standards [24,25]. The most common indications for mediolateral episiotomy are pathological fetal heart rate (FIGO score) and a tight perineum with an increased expected risk of OASIs.

For pain relief, oral analgesics as well as perinatal epidural anesthesia were available. Epidural anesthesia was not applied for water deliveries.

Water delivery is defined as the complete delivery of the baby underwater.

Other vaginal deliveries, excluding those on a bed or in water, are defined as deliveries performed on a Maia chair, a floor mattress, or in an upright position. In these positions, the women are more upright compared to deliveries performed on a bed [26,27,28].

A consultant in Obstetrics and Gynecology determined the need for a vacuum-assisted delivery. Common indications for this intervention include pathological fetal heart rate patterns and/or a prolonged second stage of labor.

Perineal injuries were classified according to the system introduced by Sultan, which has been adopted by the International Consultation on Incontinence and RCOG, as presented in Table 1 [29]. The diagnosis of OASIs was confirmed and managed by the consultant. Rectal examination was routinely performed in all cases of perineal tears.

Table 1. Classification of perineal injuries.

Degree	Extension of Injury
First degree (I°)	Injury to perineal skin and/or vaginal mucosa
Second degree (II°)	Injury to perineum involving perineal muscles but not involving the anal sphincter
Third degree (III°/OASIs)	Injury to perineum involving the anal sphincter complex
Grade 3a tear	Less than 50% of external anal sphincter thickness torn
Grade 3b tear	More than 50% of EAS thickness torn
Grade 3c tear	Both EAS and internal anal sphincter torn
Fourth degree (IV°/OASIs)	Injury to perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa

OASIs: Obstetric anal sphincter injuries; EAS: external anal sphincter; IAS: internal anal sphincter.

2.3. Study Population

For this exploratory study, primiparae who completed the questionnaire one year postpartum were included in the study population. The inclusion criteria were as follows:

• Primiparae at ≥37 + 0 weeks of pregnancy, cephalic presentation, and singleton pregnancy, regardless of comorbidities as psychiatric conditions or pre-existing chronic pain, or postpartum anxiety- or depression-disorder;
• Spontaneous vaginal delivery or vacuum-assisted delivery;
• Manual perineal protection (“hands-on”);
• Restrictive, indicated episiotomy.

The exclusion criteria were as follows:

• Preterm birth before 37 + 0 weeks of gestation;
• Multiparous women;
• Breech presentation;
• Cesarean section;
• Forceps delivery.

The variables studied were as follows:

• Maternal age.
• Fetal birth weight.
• Duration of delivery:

  ○

  Duration of first stage of labor;

  ○

  Duration of second stage of labor;

  ○

  Duration of first and second stages of labor.

• Birthing method:

  ○

  Bed delivery (reference);

  ○

  Water delivery;

  ○

  Other vaginal delivery;

  ○

  Vacuum-assisted delivery.

• Perineal injury:

  ○

  Intact perineum (reference);

  ○

  First- and second-degree perineal tear;

  ○

  OASI (third- and fourth-degree perineal tear);

  ○

  Episiotomy.

• Use of oxytocin:

  ○

  No oxytocin (reference);

  ○

  During first stage of labor;

  ○

  During second stage of labor;

  ○

  During first and second stages of labor.

Postnatal pain management for all perineal injuries included oral analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs).

Between six and eight weeks postpartum, each woman attended a follow-up consultation with her gynecologist. During this visit, recovery was assessed, with particular attention given to wound healing in cases of perineal injury.

One year postpartum, every woman who had completed the initial questionnaires was asked to complete a final self-reported questionnaire, which required 5–10 min. The questionnaire was sent to the woman regardless of her current health status or early postpartum recovery.

2.4. Outcome Measures

The primary outcome was the frequency of dyspareunia one year postpartum. Dyspareunia was reported by the women one year postpartum by answering the question: “Do you have very strong pain during sexual intercourse?” No further subclassification of superficial and deep dyspareunia was performed.

Three categories of potential influencing factors were identified.

1. Birthing methods

(a) Bed delivery (BD), (b) other vaginal delivery (OD) (Maia chair, mattress, upright position), (c) water delivery (WD), (d) vacuum-assisted delivery (VAD).

2. Perineal injuries

(a) Intact perineum (no perineal injury), (b) first- and second-degree perineal tear (I°/II°), (c) OASIs, (d) mediolateral episiotomy.

3. Use of oxytocin

(a) No use of oxytocin, (b) use of oxytocin only in the first stage of labor, (c) use of oxytocin only in the second stage of labor, (d) use of oxytocin in the first and second stages of labor.

The “a” subgroups were taken as references: bed delivery, intact perineum, and no oxytocin.

2.5. Statistical Analysis

Data were analyzed using the statistical software R, Version 4.4 [30]. Univariable statistics are presented as counts and frequencies for categorical data with p-values of odds ratios (ORs) corresponding to the chi-squared test. Multivariable logistic regression was performed to estimate ORs and corresponding 95% confidence intervals (CIs) using the rms package. Numeric variables like maternal age and birth weight were modeled non-linear using three-knot restricted cubic splines (rcs) [31]. The selection of covariates included in the model was guided by a combination of clinically relevant considerations and variables associated with the outcome in univariable analyses. The final model contained the following variables to adjust for potential confounders: maternal age, fetal birth weight, perineal injuries, birthing methods, and the use of oxytocin. A p-value < 0.05 was considered significant with a 95% confidence interval.

3. Results

3.1. Study Population

The data obtained from 3264 primiparae were analyzed. The questionnaires were returned on average 15 months postpartum (SD +/− 2 months). Desciptive data of the study population are shown in Table 2.

Table 2. Descriptive data of the study population: mean with standard deviation (SD).

		Dyspareunia	No Dyspareunia	p-Value
	Total N	N	N
	3264	476	2788
Maternal age (years)	28.5 (SD 4.09)	28.3 (SD 4.48)	28.6 (SD 4.02)	0.215
Fetal birth weight (g)	3368 (SD 422)	3374 (SD 444)	3367 (SD 418)	0.734
Duration of delivery
First stage of delivery (min)	385 (SD 193)	397 (SD 192)	383 (SD 193)	0.143
Second stage of delivery (min)	62 (SD 31.6)	60.1 (SD 48.2)	63.3 (SD 53.8)	0.208
Total delivery (min)	448 (SD 236)	455 (SD 210)	447 (SD 240)	0.485

In 232 questionnaires, information about perineal injury was not available so they were not included in the perineal injury group. The exclusion of these incomplete datasets ensured the reliability of the results and maintained internal validity across the analyses.

The mean maternal age as well as the mean fetal birth weight were comparable in the postpartum dyspareunia and no-dyspareunia group. This comparability indicates that outcome differences were unlikely to result from baseline maternal or fetal disparities.

The mean age in the study population was 28.5 years (SD 4) for the postpartum dyspareunia and the no-dyspareunia groups. The mean fetal birth weight was 3366 g (SD 430 g) for both groups. The mean duration of delivery was similar in both groups, with a total time of 448 min (SD 236). The first and second stages of labor had a mean time of 385 min (SD 193), and 62 min (SD 53), respectively. These delivery characteristics represent expected averages for primiparous women, suggesting a largely homogenous population.

In total, 15%, n = 476, of women reported postpartum dyspareunia, whereas 85%, n = 2788, reported no dyspareunia.

Moreover, 36% (n = 1198) had a bed delivery, 13% (n = 416) another vaginal delivery, 35% (n = 1137) a water delivery, and 16% (n = 513) a vacuum-assisted delivery. These distributions reflect the diversity of birthing practices in the cohort.

Intact perineum was reported in 25% (n = 762), I°/II° perineal tears in 43% (n = 1300), OASIs in 6% (n = 187), and episiotomies in 26% (n = 783).

In the postpartum dyspareunia group, intact perineum was found in 9% (n = 70), I°/II° perineal tears in 18% (n = 237), OASIs in 20% (n = 39), and episiotomies in 12% (n = 96).

3.2. Outcome

According to a univariable comparison, the frequencies of postpartum dyspareunia versus no dyspareunia in the different groups of potential influencing factors are shown in Table 3.

Table 3. Univariable comparison of frequencies of postpartum dyspareunia in the different groups of influencing factors: birthing method, perineal injury, and use of oxytocin. Bed delivery, intact perineum and no oxytocin were used as reference variables.

		Dyspareunia		No Dyspareunia		Odds Ratio [95% CI]	p-Ratio
	Total N	%	N	%	N
Birthing method	3264	100	476	100	2788
Bed delivery	1198	39.3	187	36.3	1011	Reference variable	Ref
Other vaginal delivery	416	11.6	55	12.9	361	0.83 [0.59–1.13]	0.240
Water delivery	1137	29.4	140	35.8	997	0.76 [0.60–0.96]	0.022
Vacuum delivery	513	19.7	94	15.0	419	1.21 [0.92–1.59]	0.168
Perineal injury	3032	100	442	100	2590
Intact perineum	762	15.8	70	26.7	692	Reference variable	Ref
I°/II° perineal tear	1300	53.6	237	41.0	1063	2.20 [1.67–2.94]	<0.001
OASIs (III°/IV°)	187	8.8	39	5.7	148	2.61 [1.68–3.99]	<0.001
Episiotomy	783	21.7	96	26.5	687	1.38 [1.00–1.92]	0.052
Use of oxytocin	3264	100	476	100	2788
No oxytocin	1304	35.5	169	40.7	1135	Reference variable	Ref
Oxytocin in 1st stage	68	1.5	7	2.2	61	0.79 [0.32–1.64]	0.545
Oxytocin in 2nd stage	788	23.7	113	24.2	675	1.12 [0.87–1.45]	0.37
Oxytocin in 1st and 2nd stage	1104	39.3	187	32.9	917	1.37 [1.09–1.72]	0.006

In the birthing method group, bed delivery was the reference. The frequency of postpartum was 39.3% (n = 187), while no dyspareunia was observed in 36.3% (n = 1011). Water delivery showed a significantly lower frequency of postpartum dyspareunia, with 29.4% (n = 140) compared to 25.8% (n = 997), p = 0.022.

In the perineal injury group, an intact perineum was the reference. The reported frequency of postpartum dyspareunia was 15.8% (n = 70), compared to 26.7% (n = 692) for no dyspareunia.

Both I°/II° perineal tears and OASIs were associated with significantly higher frequencies of postpartum dyspareunia: 53.6% (n = 237) versus 41.0% (n = 1063), p < 0.001, and 8.8% (n = 39) versus 5.7% (n = 148), p < 0.001, respectively.

The multivariable analysis results are shown in Figure 1 and Table 4, revealing no influence of the birthing method on postpartum dyspareunia.

Figure 1. Logistic regression model predicting postpartum with odds ratios for respective predictor and corresponding 95% confidence intervals. ¹ I°/II° perineal tears: first- and second-degree perineal tears. ² OASIs: obstetric anal sphincter injuries. Intact perineum, bed delivery, and no oxytocin were used as reference categories.

Table 4. Odds ratios, lower 0.95 and upper 0.95 confidence intervals, and p-values of the logistic regression model.

Variable	OR	Lower 0.95 CI	Upper 0.95 CI	p-Value
Maternal age (years)	1.05	0.87	1.28	0.602
Fetal birth weight (g)	0.90	0.73	1.11	0.308
Perineal injury: I/II° perineal tear vs. intact perineum	2.89	1.76	4.77	<0.001
Perineal injury: OASIs vs. intact perineum	2.54	1.25	5.16	0.010
Perineal injury: episiotomy vs. intact perineum	1.45	0.83	2.52	0.188
Birthing method: other delivery vs. bed delivery	1.13	0.68	1.90	0.632
Birthing method: water delivery vs. bed delivery	1.28	0.77	2.13	0.337
Birthing method: vacuum delivery vs. bed delivery	1.43	0.81	2.53	0.216
Oxytocin: in 1st stage vs. no oxytocin	1.06	0.30	3.71	0.924
Oxytocin: in 2nd stage vs. no oxytocin	1.40	0.89	2.22	0.148
Oxytocin: in 1st and 2nd stage vs. no oxytocin	1.52	0.98	2.33	0.059

I°/II° perineal tears (OR 2.89, 95% CI 1.76–4.77, p < 0.001) and OASIs (OR 2.54, 95% CI 1.25–5.16, p = 0.010) had a negative influence on postpartum dyspareunia compared with intact perineum. No influence was observed for episiotomies (OR 1.45, 95% CI 0.83–2.52, p = 0.188).

The analysis of oxytocin showed no influence of oxytocin in the first stage of labor (OR 1.06, 95% CI 0.30–3.71, p = 0.924). In the second stage of labor and in the group who had oxytocin in the first as well as in the second stage of labor, a trend toward a higher rate of postpartum dyspareunia was observed (OR 1.40, 95% CI 0.89–2.22, p = 0.148 and OR 1.52, 95% CI 0.98–2.33, p = 0.059). This trend suggests a possible cumulative effect, although statistical significance was not reached, warranting further investigation into larger samples.

4. Discussion

This study examined the frequency of postpartum dyspareunia one year postpartum in a cohort of primiparous women with vaginal deliveries and explored potential influencing factors. The frequency of postpartum dyspareunia in this cohort was 15%. The frequency was evaluated using only one question asking about “strong pain” during sexual intercourse. Since this question was the only question, it is likely to underestimate the real prevalence. Still, this frequency is consistent with earlier studies reporting rates of up to 35% [2,7,8]. Despite the fact that in our study every sixth to seventh woman experiences postpartum dyspareunia a year postpartum, it remains a neglected consequence of childbirth [17]. The persistence of postpartum sexual pain has important implications not only for physical recovery but also for women’s psychological health, intimate relationships, and overall quality of life.

4.1. No Influence of Birthing Method

Univariable analysis suggested that water deliveries were associated with a lower frequency of postpartum dyspareunia compared to bed deliveries. However, this influence was not confirmed in the multivariable analysis, which adjusted for potential confounders. This discrepancy suggests that factors beyond the birthing method, such as perineal injuries, labor management, breastfeeding, or pre-existing conditions, may play a more critical role in determining or developing postpartum dyspareunia.

The findings are consistent with published data. Several studies have demonstrated that the birthing method, while important for maternal satisfaction, is not itself a decisive predictor of sexual pain outcomes [15,18,32].

From a clinical perspective, these results suggest that vacuum extraction, often claimed to be more traumatic, is not necessarily associated with a higher rate of postpartum dyspareunia. This information might be useful for patient education.

Still, data about the effect of prenatal or postnatal counselling on the development of postpartum dyspareunia is non-existent. Prospective trials with validated questionnaires might give more insight in the development of postpartum dyspareunia.

4.2. Perineal Injuries Have an Influence on Postpartum Dyspareunia

Perineal injuries emerged as a significant determinant of postpartum dyspareunia. Both first- and second-degree perineal tears and OASIs were strongly associated with higher postpartum dyspareunia frequencies compared to an intact perineum. These findings align with the existing literature emphasizing the long-term impact of perineal trauma on sexual and reproductive health [33,34,35,36,37].

Interestingly, mediolateral episiotomies did not show a statistically significant influence on postpartum dyspareunia in the multivariable analysis, and the impact of first- and second-degree perineal tears was more pronounced than that of OASIs. There are several explanations for this finding:

• In this hospital setting, mediolateral episiotomies were applied restrictively and only under selected indications, like fetal distress, risk for OASI, or very tight perineum.
• Although unintentional, OASIs might be under-diagnosed as a second-degree tear.

Whether the frequency of OASIs is under- or even over-diagnosed remains unclear. Surveys confirm neither, mentioning an incidence between 1.74 and 6.1% [29,38].

The introduction of the OASI care bundle has proven effective in reducing the rate of OASIs, without affecting cesarean or episiotomy rates. Importantly, women reported feeling empowered and supported, particularly due to clear communication and respectful care. Perineal protection and episiotomies, when performed appropriately, were not negatively experienced [39]. However, the effect of the OASI care bundle on postpartum dyspareunia remains unclear. Dedicated research is needed to evaluate whether these interventions also influence long-term sexual health outcomes, particularly if antenatal information has an influence.

The literature regarding first-/second-degree perineal tears and episiotomies remains inconsistent:

• Some studies report an association between these injuries and postpartum dyspareunia [18,19,40,41], while others do not [42,43,44].
• Selective episiotomy is associated with reduced perineal trauma [45] and has shown no significant association with prolonged perineal pain or postpartum dyspareunia [45]. This aligns with our findings.
• Some data indicate improved psychophysical health 12 months postpartum among women who underwent episiotomies [19,46]. Other data show similar outcomes for postpartum dyspareunia and sexual function when comparing episiotomies and first- and second-degree perineal tears [19]. Women with episiotomies often resumed sexual activity later than others [42].

Together with previous studies, these findings suggest that episiotomies, selectively and restrictively used, do not increase the risk of postpartum dyspareunia [45].

The difference between first- and second-degree perineal tears and episiotomies remains unresolved. Gommesen et al. identified a perineal length of less than 2 cm as a potential risk factor for postpartum dyspareunia [19]. A short perineal body may follow both OASIs and larger second-degree tears. Other studies have linked more extensive second-degree tears involving more than 50% of the bulbospongiosus muscle to prolonged postpartum dyspareunia or more severe postpartum pain [40,41].

Suture techniques are another important factor. Previous research has compared continuous versus interrupted techniques.

Continuous suture techniques are associated with reduced short-term pain, less suture material, fewer complications, and better wound healing, but no clear long-term advantage for postpartum dyspareunia [34,47,48].

In our cohort, both methods were employed. While continuous suturing is faster, interrupted sutures are often preferred in more complex injuries. Training and surgical expertise thus remain critical determinants of outcomes.

4.3. Oxytocin and Its Unknown Influence

The use of oxytocin during labor did not show a statistically significant influence on postpartum dyspareunia in this study, although there was a non-significant trend toward increased risk when oxytocin was used during both the first and second stages of labor.

Oxytocin is a nonpeptide hormone widely employed for labor augmentation. Its effects extend beyond uterine contractions, influencing lactation, social behaviors, cognition, bonding, trust, and stress regulation [49].

Its broader implications for perineal tissue, pelvic floor function, pain modulation, and postpartum mood, however, remain poorly understood. Some studies suggest that oxytocin administration may lead to increased pelvic floor muscle tone, potentially predisposing to higher rates of perineal trauma, episiotomy, and OASIs [50,51]. Other research has not found such associations [52]. It might be possible that there is an association between the use of oxytocin, especially in the second stage of labor, and the rate of second-degree perineal tears. Further research is needed to detect such an association.

Experimental studies have also suggested the antinociceptive properties of oxytocin, with reduced pain sensitivity observed in some human trials, though reproducibility and clinical applicability remain uncertain [53,54,55]. Some trials have explored its use for pain relief [49,56]. But breastfeeding, which naturally elevates oxytocin levels, has been shown not to alleviate but to increase postpartum dyspareunia [57].

Rare data suggest associations between oxytocin dysregulation and postpartum mood disorders [58], highlighting the complex interplay with cortisol and other neuroendocrine pathways [59,60].

These uncertainties and multifaceted roles across physical, psychological, and sexual health highlight the need for interdisciplinary research integrating obstetrics, endocrinology, urogynecology, and pain science.

4.4. Limitation and Future Directions

This study’s strengths include its large sample size and robust statistical approach, which allowed for the adjustment of potential confounders. Over many years, the obstetric team was very consistent; and there was a well-trained team in the teaching hospital. The obstetric standard of care, including manual perineal protection and restrictive use of episiotomies, diagnosis, and treatment of tears, was well established and has stayed comparable until today. This enhanced reliability even in these rather old data. Worldwide, the “OASI care bundle” was only recently introduced and contains antenatal information for women on manual perineal protection, mediolateral episiotomy when indicated, and the diagnosis and treatment of tears [25,61]. The standard of care in this study consequently already used three of the four recommended actions, namely manual perineal protection, mediolateral episiotomy, and diagnosis and treatment of tears. This ensures comparability with modern practice.

However, the study has further limitations.

• The analysis was retrospective.
• The questionnaire used was not validated, as no questionnaire was available.
• Postpartum dyspareunia was not subclassified into deep and superficial forms.
• There was a lack of detailed information on contributing factors such as pre-existing dyspareunia, breastfeeding, hormonal status, BMI, and psychological well-being.

At the time the questionnaire was selected, no validated questionnaire for an obstetric registry existed. A nationwide quality control mechanism in obstetrics had not yet been established. In this regard, pioneering work had to be performed.

As long-term (6 months and longer) postpartum dyspareunia should be considered and treated as part of chronic pelvic pain syndrome, there are several implications for future studies. Beyond the perinatal factors analyzed in this trial, there are other already discussed suspected contributors [3,33,62,63].

The biopsychosocial model is particularly relevant here. For example, women reporting higher levels of postpartum anxiety or depressive symptoms are more likely to also report sexual pain. This may be linked to altered pain perception thresholds and reduced sexual desire, which together reinforce postpartum dyspareunia [64].

Future research should adopt prospective, multicenter designs with validated instruments for sexual health, e.g., the female sexual function index. Greater emphasis should be placed on capturing psychosocial, hormonal, and lifestyle variables. Qualitative approaches could further enrich understanding by exploring women’s subjective experiences of postpartum sexuality. Interventional studies targeting prevention and treatment—such as pelvic floor rehabilitation, topical estrogen, counseling, or partner-based therapies—are urgently needed.

The potential benefits of antenatal education regarding postpartum dyspareunia warrant further exploration. Preparing women for the possibility of sexual pain, normalizing conversations about sexual and reproductive health, and offering early interventions could help to mitigate the transition from acute to chronic pain. Early treatment of postpartum dyspareunia is essential to prevent the establishment of chronic pelvic pain syndromes.

5. Conclusions

The findings highlight the prevalence of long-term postpartum dyspareunia. This underscores the need for further research.

• Prospective trials that include the full range of potential influencing factors (e.g., pre-existing dyspareunia and psychiatric disorders, BMI, perinatal factors, and postnatal factors such as breastfeeding) are essential.
• Validated questionnaires, such as the female sexual function index, should be employed.
• Comparable standards of obstetric care, including the use of the OASI care bundle, are recommended and may facilitate comparison across studies.
• The impact of the OASI care bundle on the development of postpartum dyspareunia requires further investigation.
• The effectiveness of different prevention strategies and management approaches also warrants evaluation.

As perineal injuries are a significant influencing factor in postpartum dyspareunia, ensuring perineal integrity during childbirth through evidence-based interventions—such as manual perineal protection techniques and selective episiotomy policies—is essential. However, their potential effect on the prevalence of postpartum dyspareunia remains to be demonstrated.

Structured training in repair techniques may also affect outcomes related to postpartum dyspareunia, though more research is needed.

Follow-up consultations extending beyond the usual six-to-twelve-week postpartum period appear essential for monitoring recovery and preventing long-term postpartum dyspareunia.

Prenatal counseling should include discussion of sexual health and potential postpartum challenges. Women consistently report that they prefer healthcare professionals to initiate these conversations. The effect of such counseling on postpartum dyspareunia remains to be established.

Postpartum dyspareunia not only represents a hidden and neglected condition but also lacks robust, prospective, and comparable research. By integrating this research into a global focus, obstetric care can advance beyond survival and safety to also improve long-term quality of life and intimate health for mothers.