CASE: Waiting for an OK to resume sex
L. L. is a 29-year-old woman, G1P1, who delivered a healthy infant 4 weeks ago by spontaneous vaginal birth. The delivery involved a 2-day induction of labor for preeclampsia and a second-degree tear that was repaired without complication. The patient also experienced postpartum hemorrhage that was managed with bimanual massage and uterotonics and for which she ultimately required transfusion of blood products. Her hospital course was otherwise unremarkable.
Before pregnancy, L. L. had a normal medical history and conceived spontaneously. Her antenatal course was uncomplicated.
Today, she returns for her postpartum visit. She reports being tired and says she still has some pain at the site of the tear, but reports no problems with urinary or fecal continence. She denies being depressed, and her Edinburgh Postnatal Depression Scale (EPDS) score is consistent with that report. She is breastfeeding and appears to be doing well on the progestin-only pill for contraception. She has not yet attempted intercourse because she is complying with instructions to wait until she sees you for her postpartum visit.
How should you counsel her about resuming sexual activity?
Childbirth is a central event in a woman’s life. Pregnancy and delivery are a time of psychological, biological, and physical transformation, and the postpartum period—the “fourth trimester”—is no exception. Sexual function may be affected. In fact, many women who seek assistance for sexual dissatisfaction note that their problem arose in the postpartum period.1
Postpartum sexuality involves considerably more than the physical act of genital stimulation—with or without intromission or penile penetration—and depends on more than the physical state of recovery of the vagina (after vaginal delivery). It also depends on:
- the woman’s sexual drive and motivation
- her general state of health and quality of life
- her emotional readiness to resume sexual intimacy with a partner
- her adaptation to the maternal role and ability to balance her identity as a mother with her identity as a sexual being
- her relationship with her partner.
Given all these contributing factors, many of which fall outside the scope of the clinical practice of obstetrics and gynecology, how do we go about counseling our patients about the resumption of sexual activity?
- How can we help patients manage expectations about the quality of their postpartum sexual function?
- What guidance can we provide regarding the interplay of psychosexual and physical aspects of the puerperium?
- Can we offer a method of screening for sexual dysfunction in the puerperium? If so, will it help prevent sexual problems or hasten their resolution?
This article addresses these issues. Ultimately, the answer to the question of when to resume sexual activity should reflect an awareness of cultural norms and taboos as well as familiarity with empirically based recommendations.
Traditional postpartum sexual education is not evidence-based and has limited effectiveness. More up-to-date strategies can be easily incorporated into even the busiest clinical practice. We offer the following counseling model for you to consider when addressing the sexual health of patients postpartum.
Educate, legitimize, and normalize
The first sexual encounter after childbirth can be an important step for couples to reclaim their intimate relationship.
Adaptation to the parental role, physical healing, hormonal changes, breastfeeding, and sleep deprivation contribute to a profound psychosocial challenge. The resumption of sexual activities and a satisfying postpartum sex life depend on many variables, many of which the patient may not even be aware.
First, do not assume that all patients are heterosexual and that intercourse is their only form of sexual activity.
Second, it is important to be proactive in antepartum and postpartum counseling and to offer anticipatory guidance. Counseling can take place any time during routine prenatal care, as well as at the time of hospital discharge and the postpartum visit.
Reassure the patient that, if sexual activity and frequency are lower during pregnancy and the postpartum period, it is likely a normal transition. Also give the patient time to talk about her expectations and perceptions. Explain to her the normal fluctuations and variability of sexual interest and enjoyment in pregnancy and the puerperium, and suggest that she consider alternative options for intimate expression, non-coital sexual activities, and mutual pleasure within her cultural context.
Take a comprehensive medical, obstetric, psychological, and social history as part of the sexual history. Also perform a physical intake and exam. Questions about urinary and fecal incontinence ought to be part of all postpartum assessment.
Other potential areas to address include the quality of the relationship, prepregnancy sexual function, the support network, planned or unplanned state of the pregnancy, previous pregnancy and delivery outcomes, the health status of current children, and present, previous, and future contraceptive use.29
Consider multiple visits
It is hard to know exactly when to evaluate a patient for postpartum sexual dysfunction, given the impact of pudendal nerve latency, fatigue, and breastfeeding. For this reason, assessment on multiple occasions may be appropriate. Numerous validated scales to assess sexual function can be easily incorporated into clinical practice.
Couples counseling and therapy may be needed in some cases; be aware of referral services in your area for sexual wellness specialists.
The bottom line: A “successful” sexual life does not necessarily mean adequate genital function (e.g., coital orgasm, improved clitoral blood flow, increased sexual frequency) but, rather, a sexual life that is intimate and satisfying to the individual patient.