Pregnancy and delivery inevitably lead to a number of lifestyle adjustments in a woman’s life. These include sexual difficulties, which are very prevalent in the short term. From one-fifth to almost four-fifth of postpartum women complain of decreased satisfaction in this area following childbirth.
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Physically speaking, a woman can have intercourse when the integrity of the perineum has returned and lochial discharge ceases. This may be complete within two to four weeks postpartum, but varies between individual women.
Many women do not desire sexual activity at this time, to allow proper healing to occur. If a woman returns to her doctor with a gaping episiotomy, one reason may be premature sexual activity prior to proper perineal healing, often forced by her partner.
Most women are often disinclined for physical intimacy at this time. Perineal soreness is common following vaginal childbirth, especially if instrumental delivery, an episiotomy, or major laceration, occurred.
This may lead to a delay in the woman’s ability to consider and enjoy vaginal intercourse again. It is important to allow all stitches, including the internal sutures, to heal and dissolve completely, before resuming sexual activity.
A cesarean section is a major abdominal operation and women will need more time to recover from it. Once the sutures are removed, the scar is usually healed. However, care should be taken to ensure that no pressure or weight is put on it during sexual activity for a few months.
If it is still tender, the situation should be discussed with the partner and necessary adjustments made in sexual techniques.
Fatigue secondary to the stress of childbirth and caring for the baby, with lack of sleep, breastfeeding, and dealing with the needs of other members of the family, if any, is a potent inhibitor of sexual desire. In addition, prolactin levels rise during lactation. Prolactin is a hormone which reduces sexual interest.
Vertical Transmission of Infection
If the new mother is likely to have intercourse with partners who may transmit HIV and other sexually transmitted infections (STIs), it is recommended that they do not have sex for at least six weeks. This is because the risk of transmitting the infection to the infant through breast milk is much higher, by a factor of three, if the STI is newly acquired within this time.
Again, the presence of cuts, lacerations, and abrasions following childbirth increases the risk of being infected during the first few weeks.
Desire to Postpone or Avoid Conception
It is important for women to assess their health, desire for future childbearing, and risk of puerperal infection, well before they return to their home environments. For this reason, such topics should be discussed during the latter part of pregnancy, with both partners if possible, to evolve a concrete plan of action, which may involve abstinence for a period.
At the same time, unwarranted fears may be dispelled if the woman is allowed to express them and receive information about the postpartum period.
The availability of support from the spouse, and other family members, or from other sources, is a prime factor in the woman’s comfort level with sexual intercourse following childbirth.
Postpartum blues, or actual postpartum depression, may afflict up to a third of women following childbirth. This is strongly associated with low sex drive. It is important to take advantage of health services to deal with this problem, and to arrange for social and family support during this demanding time.
Many women fear that their body has become unattractive because of the changes that occurred during pregnancy and childbirth. A sagging abdomen, lacerations of the perineum, and large breasts, as well as weight gain, chloasma, and milk secretion, are just some of the changes cited by women.
This may take some time for women to accept them as part of the process of having a baby, but if these feelings are severe, it is wise for the woman to discuss them with her partner or with her healthcare provider. When women do not accept their own bodies, they often lose sexual desire as a result of fear and inhibition.
Feeling of Being Forced to Have Sex
Many women complain of feeling pressurized into resuming sexual intercourse before they are emotionally ready for it. This may indicate wrong reading of a partner’s signals, and communication lines should therefore be kept clear and open.
Women should be encouraged and taught to convey their real feelings gently but truthfully, and negotiate for an acceptable solution, in such situations. This may involve settling for cuddling and foreplay for some days, until actual vaginal sex is welcome to both partners.
Affection and reassurance can go a long way in softening the blow of not wanting full intimacy, dispelling the feeling of rejection that this often conveys to the male partner. In many cases, the male partner is just as concerned that the woman not suffer pain during intercourse, and tactful honesty can help work through the feelings of both people involved in the relationship.
As said above, some women do resume sexual activity by two weeks postpartum, but on average, eight weeks is the usual initiation point following childbirth. It may be reassuring to know that full sexual satisfaction is rare at this time.
Causes for this range from decreased sensation in the perineum, pain during penetration, inhibition about the changed shape of the body, milk secretion with arousal, to simple tiredness or sleep deprivation.
Even at six months, almost one in four first-time mothers rate their sexual satisfaction as less than that before childbirth. Dyspareunia occurs in more than a fifth of these women, and is often associated with a history of operative vaginal delivery. This is probably because of the increased risk of episiotomies, major perineal lacerations (especially of the anal sphincter), infective complications, and delayed return of perineal integrity, in these women.
It is interesting that there is no significant difference at six months with respect to pain during sexual intercourse, between women who had vaginal delivery and those who underwent cesarean delivery.
Reviewed by Susha Cheriyedath, MSc