Clinical Review

How to prepare your patient for the many nuances of postpartum sexuality

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In 1998, von Sydow performed a meta-content analysis of all existing studies on parental sexuality during pregnancy and the first 6 months postpartum.7 Using psychological and medical data banks, she brought together information from two branches of science and identified 59 relevant studies in English or German between 1950 and 1996. Although the majority of studies were retrospective and failed to utilize a validated instrument, von Sydow determined that, overall, sexual interest and activity were low or nonexistent during the first months after delivery. There was high variability between individuals, however, and levels of sexual interest and activity of individual women remained relatively constant from the time before pregnancy until 1 year postpartum.7 von Sydow determined that there is great variability in female sexuality during pregnancy and postpartum; this variability may represent fluctuations during this phase of life. She also determined that severe psychosexual and marital problems are much more prevalent in the postpartum period than during pregnancy and persist long after a physical cause can be used as an explanation.7

Fatigue and quality of the relationship have an impact on sexual function

De Judicibus and colleagues identified a broad range of variables that have a detrimental impact on sexuality at 12 weeks postpartum, most particularly:

  • marital dissatisfaction
  • dyspareunia
  • fatigue
  • depression
  • breastfeeding.2

There is evidence to suggest that the addition of the first child reduces marital quality after the first month postpartum, and this decline in marital satisfaction continues for 6 to 18 months postpartum.2 Witting and coworkers suggested that this decline may represent a transitional phase of parenthood for some couples; data support the positive effects on overall marital satisfaction with the addition of children.8 Women who were more satisfied with their relationships reported higher sexual satisfaction and greater frequency of intercourse.2,8

Fatigue is one of the most common problems women experience during pregnancy and postpartum and is a common reason given for loss of sexual desire and interest, infrequent sexual activity, and lack of enjoyment.5 A high level of exhaustion is found during the first 8 weeks postpartum. Although it declines over the next 6 months, it does not appear to resolve completely in a good number of women.9

Don’t underestimate the impact of obstetric morbidity

Surprisingly, the long-term impact of severe obstetric events on postpartum maternal health is often overlooked. Waterstone and colleagues found that women who have severe obstetric morbidity, such as massive hemorrhage, preeclampsia, sepsis, and uterine rupture, experience significant changes in sexual health and well-being.10 They conducted a prospective cohort study of such women, measuring sexual activity, general health, and postpartum depression. They utilized two validated postnatal questionnaires—the Short Form 36 (SF-36) to measure general health and the EPDS. Women who had uncomplicated pregnancies and childbirth tended to perform well in most SF-36 categories, whereas women who had experienced severe morbidity scored worse in almost every category. These women also reported problems with intercourse. Thirteen percent of women had not resumed sexual relations by 6 to 12 months postpartum; of these women, more than half reported a fear of conceiving as a reason.

The female body undergoes dramatic changes after delivery

The female body undergoes dramatic physiologic, anatomic, and psychological changes immediately following delivery and throughout the restoration of its pre-pregnant state. This fourth trimester usually lasts 6 to 12 weeks.39

Uterus. The uterus undergoes rapid involution after separation of the placenta. By 2 to 4 weeks postpartum, it may no longer be palpable abdominally, and by 6 weeks, it usually has returned to its nonpregnant state and size. Seven to 14 days after delivery, a woman often experiences an episode of heavier vaginal bleeding that corresponds with the sloughing of the placental bed eschar. During this time of involution, myometrial vessels may be 5 mm or larger in diameter.40

Lochia. The postpartum lochia begins to change within days of birth, transitioning through its stages of lochia rubra, serosa, and alba. It decreases by 3 weeks postpartum and is likely completely resolved by 6 weeks.

Prolactin is responsible for lactogenesis. When the prolactin level is maintained through breastfeeding, it depresses ovarian production of estrogen by suppressing pituitary gonadotropin secretion, triggering a period of “steroid starvation” after the loss of estrogen and progesterone production from the placenta.1

Vagina. Early in the postpartum period, the vagina is typically edematous and lax and, as a result of parturition, there may be not only a spontaneous tear or episiotomy that must heal, but superficial small tears that do not require suturing. Ruggae begin to reappear by 3 weeks, and the vaginal epithelium will begin to mature under the influence of estrogen production. Much of this tissue damage is healed by 6 weeks postpartum.

The perception of pregnant and postpartum women’s sexuality varies, based on religious and cultural norms. In some religions and cultures, sexual activity is forbidden for 2 to 3 months postpartum; in others, it is prohibited until the child is weaned from the breast. The postpartum woman and lochia have traditionally been perceived as unclean, and many religions have specific proscriptions regarding the management of this time in a woman’s life.1 Although early cultures did not study these issues specifically, their doctrines suggest that they had some awareness of the natural physiologic transition of a woman’s body after she has given birth.

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