Sexual Changes During and After Preparing new parents with perspective, evidence, and resources.

hile pregnancy and the remained the same during the Function. Erol and colleagues birth of a baby bring first and second trimesters, only found a general decline in female joy to many parents, to ­decrease significantly in the sexual function from the first to W 1 they may also have significant third. In a study of 40 pregnant the third trimester in 589 healthy effects on both sexual function women in Turkey, Aslan and col­ pregnant women assessed with and frequency. Discussing with leagues found that “sexual inter­ the Index of Female Sexual Func­ your patients potential changes in est [was] unchanged or slightly tion questionnaire.5 The ques­ their sex lives can make it easier decreased in the first trimester, tion­naire assesses for sexual for them to adapt in a timely and variable in the second trimester dysfunction in the following mutually satisfying way. and decreased sharply at the end areas: of the third trimester.”2 This pro­ • vaginal discomfort Sex during Pregnancy nounced reduction in women’s • vaginal dryness Frequency. Research and anec­ sexual desire in the third trimester • decrease in sexual desire dotal evidence generally support is further supported by a German • sexual life dissatisfaction the truism that couples experience study of 30 couples that found • orgasmic dysfunction a decline in sexual activity (includ­ that solo masturbation in preg­ • diminished clitoral sensation ing manual breast and genital nant women remained relatively In assessing sexual function stimulation, oral sex, and sexual constant until the last trimester, during pregnancy and in the post­ intercourse) during pregnancy, when it declined significantly.4 partum period, Pauls and col­ with by far the greatest reduction French kissing and male mas­ leagues used the Female Sexual in the third trimester.1-3 Pauleta and turbation, however, remained Function Index (which assesses colleagues found that the prepreg­ ­relatively stable throughout the desire, arousal, lubrication, or­ nancy frequency of intercourse pregnancy period. gasm, satisfaction, and pain) and found that declines in desire, arousal, lubrication, and orgasm continued for six months after women gave birth.3 Such changes in sexual function may be related to other variables of pregnancy, including the woman’s levels of nausea and fatigue in the first tri­ mester, the effects of increasing girth in the second and third tri­ mesters, and positive or negative cultural attitudes toward sex in pregnancy in general.

Sex after While most women will return to their usual level of sexual func­tioning at about six months after delivery,6 some will encoun­ ter ­challenges from lingering effects of the pregnancy or birth

Photo © Radius Images / Alamy. processes.

50 AJN t August 2010 t Vol. 110, No. 8 ajnonline.com By Anne Katz, PhD, RN

Trauma to the . ­affect a woman’s feelings of attrac­ Australia, women reported feeling Medical interventions such as tiveness as well as the impact it fatter and less fit six months after episi­otomy at the time of delivery might have on her sexual partner. giving birth than they did before can result in trauma to the soft Pelvic pain and pregnancy and also reported a tissue of the . Women may be due to perineal trauma, greater discrepancy be­tween their who’ve had a significant perineal as discussed earlier, or to vaginal perceived current size and their laceration, with damage to the dryness associated with altered ideal size after pre­gnancy than skin and muscles of the perineum hormone levels during breast­ before.16 The authors suggest that up to and including a tear in the feeding.8 Fear of pain may also societal expectations may influence anal sphincter, are the least likely decrease arousal and lubrication, women’s body image after delivery, to resume sexual activity within in turn leading to more pain dur­ with six months postpartum con­ one year.7 ing intercourse.9 sidered the time by which women Spontaneous perineal lacera­ Psychosocial factors. Body should have returned to close tions can effect sexual function­ image is important to how women to their prepregnancy size and ing; women with more significant see themselves as sexual beings. shape. Certainly, pictures of new (second, third, or fourth degree) In a study of 79 new mothers in Hollywood moms—who seem to tissue damage report less desire to be held or stroked by their part­ ner than those who experienced superficial (first degree) tears.8 Using the PLISSIT Model to Talk About Sex with In a study of 248 primiparous women, those who’d had a ce­ New Parents sarean section were more likely to return to prepregnancy sexual Permission: activity within six months than All nurses should be able to function at this level—for example, to make a gen- those who’d had an .9 eral statement that normalizes the topic. Incontinence. Women who • Example: “It may feel like you’ll never have sex again with a new baby in have urinary or the house, but it will happen. If you notice anything different, you can talk are less likely to resume sexual to your gynecologist about it at your next visit.” activity after childbirth.10 In one study of 50 women, more than Limited Information: 75% had at least occasional Most nurses should be able to give this kind of information. ­ at six months • Example: “Many mothers notice some vaginal dryness that gestation, compared with 34% can make sex uncomfortable. This is due to hormonal changes and can be at six months postpartum.11 Re­ treated with a lubricant. You may want to try using one.” searchers have found rates of uri­ nary incontinence from 10.5% to Specific Suggestion: 23% one year postpartum.12, 13 Requires a higher level of expertise on the part of the nurse, who must be able Incontinence is associated with to provide anticipatory guidance on the possible sexual consequences of giving the use of epidural anesthesia and birth or on normal postpartum changes. the length of the second (pushing) • Example: “You had a third-degree tear during delivery that may cause some stage of labor; those pushing for pain if you try to have intercourse. You may want to wait a while longer more than an hour may experi­ before resuming intercourse, or make sure you allow enough time and stim- ence the most incontinence after ulation for arousal. Some women find that using a lubricant helps, while delivery.12 In a study of 75 women, others avoid intercourse and instead rely on oral and manual stimulation.” anal incontinence was associated with the use of forceps during de­ Intensive Therapy: livery.14 There’s good evidence Usually requires a referral to a sex therapist or specially trained counselor. that pelvic floor muscle training • Example: “It sounds like you and your partner are really being challenged and exercises can be of benefit in at this time. Having a new baby can put a lot of strain on a relationship. urinary incontinence15; however, I think you’d both benefit from seeing one of our social workers who can the evidence for their efficacy help you communicate more effectively.” in anal incontinence is weaker. It should be easy to understand Annon JS. The behavioral treatment of sexual problems. Honolulu, HI: Enabling Systems; 1974. how leakage of urine or feces can [email protected] AJN t August 2010 t Vol. 110, No. 8 51 return to their ideal form within • What methods of birth con­ REFERENCES weeks—support this belief. trol are appropriate? 1. Pauleta JR, et al. Sexuality during Other factors also play a • What sexual changes can we preg­nancy. J Sex Med 2010;7(1 Pt 1): 136-42. role. The relationship between expect after having a baby? 2. Aslan G, et al. A prospective analysis first-time parents is irrevocably At 12 months, couples wanted of sexual functions during pregnancy. changed by the new family mem­ to know how to deal with the Int J Impot Res 2005;17(2):154-7. ber. Some women have told me woman’s body image issues and 3. Pauls RN, et al. Effects of pregnancy on female sexual function and body that being a new mother seems how to cope with discrepancies image: a prospective study. J Sex Med discordant with that of being a in desire, since men tended to 2008;5(8):1915-22. sexual partner. The demands of want sex more than their part­ 4. von Sydow K, et al. Sexual activity during pregnancy and after childbirth: new parenthood include sleep­ ners. Child-rearing differences results from the Sexual Preferences less nights, anxiety, and a focus also affected the relationship.17 Questionnaire. J Psychosom Obstet on the baby—all of which divert Discussion is essential. Not all Gynaecol 2001;22(1):29-40. 5. Erol B, et al. A cross-sectional study of attention from the sexual aspects nurses are comfortable discussing female sexual function and dysfunction of the relationship; this, in turn, sexual issues with patients; many during pregnancy. J Sex Med 2007; can lead to relationship stress. may feel there isn’t enough time 4(5):1381-7. The role of the partner seems to to do so, especially with all of 6. Brubaker L, et al. Sexual function 6 months after first delivery. Obstet be a determining factor in how their other responsibilities. And Gynecol 2008;111(5):1040-4. quickly a couple resumes sexual if patients don’t raise questions, 7. van Brummen HJ, et al. Which factors activity; if the partner expresses nurses might assume that sexual determine the sexual function 1 year after childbirth? BJOG 2006;113(8): a strong desire for sex, it’s more issues aren’t important to them. 914-8. likely to happen. An example of how to talk to 8. Rogers RG, et al. Does spontaneous new parents about sexuality is genital tract trauma impact postpar­ tum sexual function? J Midwifery What Can Nurses Do? provided in Using the PLISSIT Womens Health 2009;54(2):98-103. Nurses have traditionally used Model to Talk About Sex with 9. Baksu B, et al. The effect of mode of anticipatory guidance as part of New Parents. delivery on postpartum sexual func­ pre- and postnatal education. At the very least, raise the tioning in primiparous women. Int Urogynecol J Pelvic Floor Dysfunct How­ever with shorter hospital topic of sexuality and let patients 2007;18(4):401-6. stays for women giving birth, there know that it can be an issue. Let 10. Handa VL, et al. The impact of fecal isn’t often enough time to talk them know that there’s help out and urinary incontinence on quality of life 6 months after childbirth. Am J about sex—especially when new there if they encounter difficulties. Obstet Gynecol 2007;197(6):636 parents’ attention is on a myriad Most consumer books on preg­ e1-e6. of other concerns such as breast­ nancy, childbirth, and 11. Pauls RN, et al. Effects of pregnancy on pelvic floor dysfunction and body feeding, bathing, sleep patterns, include sections on sexuality both image; a prospective study. Int Urogy- and comforting the baby. Sexual­ during and after pregnancy. En­ necol J Pelvic Floor Dysfunct 2008; ity may be the last thing on their courage expecting and new par­ 19(11):1495-501. minds. ents to revisit these sections. There 12. Serati M, et al. Prospective study to as­ sess risk factors for pelvic floor dys­ Attitudes toward sexuality in are also many popular parenting function after delivery. Acta Obstet pregnancy are often influenced Web sites that provide specific Gynecol Scand 2008;87(3):313-8. by culture. Ask your patients sections, blogs, or columns about 13. van Brummen HJ, et al. Bothersome lower urinary tract symptoms 1 year what they’ve been taught about sexuality. after first delivery: prevalence and the sexuality in the perinatal period Some couples will need more effect of childbirth. BJU Int 2006; and keep this in mind when pro­ help; in such cases, a referral to 98(1):89-95. 14. O’Boyle AL, et al. Anorectal symptoms viding guidance. Review your a marital or sex therapist may in pregnancy and the postpartum pe­ opinions about this subject and be necessary. For women who’ve riod. J Reprod Med 2008;53(3):151-4. remember to hold these in check experienced perineal trauma, a 15. Harvey MA. Pelvic floor exercises when advising patients. referral to a pelvic floor therapist during and after pregnancy: a system­ atic review of their role in preventing A recent study offers insight may be helpful in alleviating pain pelvic floor dysfunction. J Obstet Gy- into what new parents want to and dealing with the aftermath of naecol Can 2003;25(6):487-98. know about sexuality during the damage to the pelvic floor. t 16. Rallis S, et al. Predictors of body image 17 during the first year postpartum: a pro­ first year after delivery. At four spective study. Women Health 2007; months postpartum, men and Anne Katz is a clinical nurse specialist 45(1):87-104. women had similar questions: and sexuality counselor at CancerCare 17. Pastore L, et al. Postpartum sexuality Manitoba in Winnipeg, Manitoba, concerns among first-time parents • When can we resume inter­ Canada. She also coordinates Sexually from one U.S. academic hospital. J Sex course? Speaking: [email protected]. Med 2007;4(1):115-23.

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