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How to Prepare Your Patient for the Many Nuances of Postpartum Sexuality

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How to Prepare Your Patient for the Many Nuances of Postpartum Sexuality How to prepare your patient for the many nuances of postpartum sexuality Up-to-date strategies for educating and advising your patient are more effective (and efficient) than traditional counseling Roya Rezaee, MD, and Sheryl Kingsberg, PhD CASE Waiting for an OK to resume sex Before pregnancy, L. L. had a normal L. L. is a 29-year-old woman, G1P1, who medical history and conceived spontaneously. delivered a healthy infant 4 weeks ago by Her antenatal course was uncomplicated. spontaneous vaginal birth. The delivery Today, she returns for her postpartum involved a 2-day induction of labor for visit. She reports being tired and says she preeclampsia and a second-degree tear that still has some pain at the site of the tear, but was repaired without complication. The patient reports no problems with urinary or fecal also experienced postpartum hemorrhage continence. She denies being depressed, that was managed with bimanual massage and her Edinburgh Postnatal Depression In thIs and uterotonics and for which she ultimately Article Scale (EPDS) score is consistent with that required transfusion of blood products. Her report. She is breastfeeding and appears to A model for hospital course was otherwise unremarkable. be doing well on the progestin-only pill for counseling contraception. She has not yet attempted intercourse because she is complying with page 26 Dr. Rezaee is Assistant Professor of Obstetrics and instructions to wait until she sees you for her Gynecology at the University postpartum visit. The 6-item Hospitals Case Medical How should you counsel her about Female Sexual Center, MacDonald Women’s Hospital, and Medical Director resuming sexual activity? Function Index of the Women’s Health page 29 Center at the University Hospitals Case Medical Center in Cleveland, Ohio. hildbirth is a central event in a wom- The female body Dr. Kingsberg is Chief of an’s life. Pregnancy and delivery are undergoes striking the Division of Behavioral a time of psychological, biological, Medicine at the University C changes after Hospitals Case Medical and physical transformation, and the post- delivery Center, MacDonald Women’s partum period—the “fourth trimester”—is Hospital, and Professor of page 32 Reproductive Biology and no exception. Sexual function may be affect- Psychiatry at Case Western ed. In fact, many women who seek assistance Reserve University School of for sexual dissatisfaction note that their prob- Medicine in Cleveland, Ohio. lem arose in the postpartum period.1 On the Web Dr. Rezaee receives grant or research support Postpartum sexuality involves consid- from Paladin Technologies. Dr. Kingsberg erably more than the physical act of genital 5 tips for talking to receives grant or research support from BioSante patients about and Paladin Technologies, and is a consultant to stimulation—with or without intromission or postpartum BioSante Pharmaceuticals, Pfizer, Norvo Nordisk, penile penetration—and depends on more Viveve, Trimel Pharmaceuticals, and Sprout sexuality, at Pharmaceuticals. than the physical state of recovery of the vagi- obgmanagement.com na (after vaginal delivery). It also depends on: 24 OBG Management | January 2012 | Vol. 24 No. 1 obgmanagement.com Postpartum sexuality ock t rs tte shu : O t ho P • the woman’s sexual drive and motivation A paucity of research • her general state of health and quality of To date, research into sexuality during the life postpartum period has focused primar- • her emotional readiness to resume sexual ily on the physical changes and constraints intimacy with a partner that affect the mechanics and frequency of • her adaptation to the maternal role and intercourse and overall sexual satisfaction ability to balance her identity as a mother and desire.2 This perspective has begun to Many women who with her identity as a sexual being broaden to include the psychological aspects seek assistance • her relationship with her partner. of sexuality. for sexual Given all these contributing factors, Women’s sexual health during the post- dissatisfaction report many of which fall outside the scope of the partum period has generally been under- that their problem clinical practice of obstetrics and gynecology, researched. It wasn’t until the past decade arose postpartum how do we go about counseling our patients that validated sexual function questionnaires about the resumption of sexual activity? were utilized. Although a number of these Other questions: instruments are now available (TABLE 1, • How can we help patients manage expec- page 28; TABLE 2, page 29; FIGURE, page 30), tations about the quality of their postpar- it remains unclear whether they can accu- tum sexual function? rately measure postpartum sexual function. • What guidance can we provide regarding Despite these limitations, significant infor- the interplay of psychosexual and physical mation has been elicited that can be used to aspects of the puerperium? counsel patients struggling with postpartum • Can we offer a method of screening for sexual concerns. sexual dysfunction in the puerperium? If so, will it help prevent sexual problems or Ideal period of abstinence is unknown hasten their resolution? Although our knowledge of the female geni- This article addresses these issues. Ultimately, tal tract in the puerperium is based upon the answer to the question of when to resume histologic evidence, there are no evidence- sexual activity should reflect an awareness of based policies to outline the ideal period cultural norms and taboos as well as familiar- of postpartum coital abstinence. It seems ity with empirically based recommendations. reasonable to assume that our traditional obgmanagement.com Vol. 24 No. 1 | January 2012 | OBG Management 25 Postpartum sexuality scientific recommendations developed in by the American College of Obstetricians part to prevent uterine infection and dis- and Gynecologists (ACOG) in 1984.1 In 1985, ruption of sutured wounds. These concerns, Pritchard and colleagues wrote about the in- combined with cultural and societal norms, dividualization of postpartum prohibitions have led to the routine discouragement of of sexual activity in Williams Obstetrics.1 sexual activity until 4 to 6 weeks postpartum. The earliest time at which intercourse may The possibility of shortening the period be safely resumed is unknown, but the 23rd of postpartum abstinence was first suggested edition of Williams Obstetrics states that a How to counsel patients about postpartum sex traditional postpartum sexual education is for intimate expression, non-coital sexual not evidence-based and has limited effec- activities, and mutual pleasure within her tiveness. More up-to-date strategies can cultural context. be easily incorporated into even the busi- est clinical practice. We offer the following Be thorough counseling model for you to consider when addressing the sexual health of patients take a comprehensive medical, obstetric, postpartum. psychological, and social history as part of the sexual history. Also perform a physical intake and exam. Questions about urinary Educate, legitimize, and normalize and fecal incontinence ought to be part of all postpartum assessment. the first sexual encounter after childbirth can Other potential areas to address include be an important step for couples to reclaim the quality of the relationship, prepreg- their intimate relationship. nancy sexual function, the support network, Adaptation to the parental role, physi- planned or unplanned state of the pregnancy, Be proactive cal healing, hormonal changes, breastfeed- previous pregnancy and delivery outcomes, in antepartum ing, and sleep deprivation contribute to the health status of current children, and and postpartum a profound psychosocial challenge. the present, previous, and future contraceptive counseling about resumption of sexual activities and a satis- use.29 fying postpartum sex life depend on many issues related to variables, many of which the patient may not Consider multiple visits sexuality. For even be aware. example, explain First, do not assume that all patients are It is hard to know exactly when to evaluate that a postpartum heterosexual and that intercourse is their only a patient for postpartum sexual dysfunction, decrease in the form of sexual activity. given the impact of pudendal nerve latency, Second, it is important to be proactive in fatigue, and breastfeeding. For this reason, frequency of sexual antepartum and postpartum counseling and assessment on multiple occasions may be activity is normal. to offer anticipatory guidance. Counseling appropriate. Numerous validated scales to can take place any time during routine pre- assess sexual function can be easily incorpo- natal care, as well as at the time of hospital rated into clinical practice. discharge and the postpartum visit. Couples counseling and therapy may be Reassure the patient that, if sexual activ- needed in some cases; be aware of refer- ity and frequency are lower during pregnancy ral services in your area for sexual wellness and the postpartum period, it is likely a specialists. normal transition. Also give the patient time the bottom line: A “successful” sexual to talk about her expectations and percep- life does not necessarily mean adequate tions. explain to her the normal fluctuations genital function (e.g., coital orgasm, im- and variability of sexual interest and enjoy- proved clitoral blood flow, increased sexual ment in pregnancy and the puerperium, and frequency) but, rather, a sexual life that is inti- suggest that she
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