Clinical Review

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

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Exploring the role of body image

Paul and coworkers prospectively assessed female sexual function, body image, and pelvic symptoms from the first trimester until 6 months postpartum.11 They utilized the validated questionnaire instruments of the Female Sexual Function Index (FSFI), the Body Exposure during Sexual Activities Questionnaire (BESAQ), the short forms of the Urogenital Distress Inventory (UDI-6), the Incontinence Impact Questionnaire (IIQ-7), and the Fecal Incontinence Quality of Life Scale (FIQOL). They found that sexual activity and sexual function scores were highest before pregnancy, declined between the first and third trimesters, and did not return to pre-pregnancy baselines even by 6 months postpartum.11

Differences in sexual practices contributed to these patterns. Kissing, fondling, and vaginal intercourse remained stable across pregnancy, whereas oral sex, breast stimulation, and masturbation declined in the third trimester.

The decline of these activities during pregnancy and postpartum has been seen in other studies as well.12

Obstacles to sexual activity also changed across pregnancy and the postpartum period. Vaginal pain was more problematic in the third trimester and postpartum, whereas feelings of unattractiveness and issues of body image were present throughout pregnancy and at their worst in the postpartum period. Sexual function scores based on the FSFI declined during pregnancy and did not return to pre-pregnancy or first-trimester levels by 6 months postpartum. Urinary symptoms, as measured by the UDI-6, were associated with lower sexual function scores during the postpartum period. The association between urinary incontinence and sexual dysfunction has been seen in other studies.13,14

The enduring effects of perineal trauma

Childbirth may physically affect a woman’s sexual function through perineal trauma, pudendal neuropathy, and vaginal dryness associated with breastfeeding. There is an obvious connection between perineal laceration and perineal pain and problems with intercourse.5 Overall, dyspareunia is reported by 41% to 67% of women 2 to 3 months after delivery.15 Women who have an episiotomy complain of increased perineal pain and delayed return of sexual activity, compared with women who deliver with an intact perineum.16

Persistent dyspareunia is strongly associated with the severity of perineal trauma and operative vaginal delivery.3,17 Multiple studies have investigated this association and found a positive correlation 3 to 6 months postpartum,6,9,17 but the long-term effects and association remain unclear.18

Findings from research. Rogers and colleagues prospectively studied the effect of perineal trauma on postpartum sexual function in a midwifery population of women who had a low rate of episiotomy and operative vaginal delivery.6 They utilized the Intimate Relationship Scale (IRS), a validated questionnaire to measure postpartum sexual function in couples. Most women in this study had resumed sexual activity by 3 months postpartum and did not have postpartum inactivity or dysfunction, based on their IRS scores. However, women who were identified as having experienced major trauma (second-, third-, or fourth-degree laceration or a repaired first-degree laceration) had significantly less desire to engage in activities such as touching and stroking with their partner.6

Present-day limits on the routine use of episiotomy and operative vaginal delivery have yielded a lower rate of third- and fourth-degree laceration.19 Second-degree lacerations are common and constitute the majority of perineal trauma in births without episiotomy.20 There is evidence that the use of synthetic absorbable suture, such as polyglactin, rather than chromic suture, results in less postpartum perineal pain, as does leaving the well-approximated perineal skin edges unsutured.20

Signorello and coworkers found that second-, third-, and fourth-degree lacerations increased the risk of postpartum dyspareunia; operative vaginal delivery (forceps or vacuum) was also an independent risk factor for dyspareunia.21

The impact of route of delivery

Some researchers have concluded that the route of delivery has an impact on the long-term pelvic floor health of women.18 In 1986, Snooks and colleagues analyzed possible obstetric risk factors for damage to the innervation of the pelvic floor, which can lead to both stress urinary and anorectal incontinence.22 They found that the process of vaginal delivery causes a compression and stretch type of injury to the pudendal nerve, as well as the possibility of severe perineal lacerations. This injury may be less likely to occur when cesarean delivery is performed before labor, avoiding direct perineal trauma and possible pudendal neuropathy.15 Because the pudendal nerve mediates some of the reflex pathways in the female sexual response, it is plausible that damage to it could result in sexual dysfunction.

Women who deliver vaginally have a higher rate of fecal and urinary incontinence than women who deliver by cesarean.16,23 The presence of incontinence, however, does not always have a significant long-term effect on one’s sexual life.6

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