POST-PARTUM SEX

One of the most intriguing things about working with women is the ease with which rapport is established once they feel comfortable with the topic at hand and do not feel judged for having a difference of opinion. These discussions will happen in any setting and hence in many instances, being a gynaecologist means occasionally having to clarify medical issues outside of the office.

In one such instance, the very interesting conversation of when to resume sexual activity after childbirth came up. The opinions around the table were expressed with utmost humor but reflected the reality that it is not a topic that is much discussed in the doctor’s office.

One of us, a mother of one, was absolutely dumbfounded by what she was hearing and was quiet or a long time. When she finally spoke, her surprise was genuine. She could not understand how one would wait for weeks to resume sex. She had undergone a normal delivery and in less than a week, it was business as usual for her. Suffice it to say, she elicited lots of laughter.

So what is deemed as the correct time to resume sexual intercourse after birth? There is no fast rule except that one needs to wait for lochea (the bleeding that occurs after delivery) to dry up. The rest is quite subjective.

Lucy* underwent a normal delivery for her first child. She had a fairly easy time, with a short labour and a relatively small baby born at 2700g. She did not need an episitomy (a cut made by the doctor or midwife to increase the vaginal outlet at birth to ease delivery of the baby) and she did not sustain any tears in the peri-vaginal area. After birth, she recovered fairly quickly and within two weeks she had stopped bleeding. By the third week, she comfortably had her first sexual encounter and other than the unruly breast milk splashing all over, she did not really complain.

Fast forward to seven years later when her second baby came. Things were different. She had an uneventful pregnancy but at birth, her delivery was complicated. Her baby weighed 4000g and she had shoulder dystocia, a complication where the baby’s head is born but the shoulders get stuck in the pelvis, putting the baby at risk of suffocating. The response by the medical team is swift and aggressive and the mother may not comprehend what is happening to save her baby’s life. It was not a good experience for her. She had an episiotomy and a fair amount of bruising. Despite healing well afterwards, she was scared to engage in sexual intercourse because she thought she would be in pain. It took a lot of counselling and reassuring to be able to resume a normal sex life.

Resuming a healthy sexual life is dependent on a triad of good physical, mental and psychological state. The body naturally has a great capacity to heal after birth. The episiotomy given or the tears sustained will heal in three to six weeks, as will the drying up of the lochea. The uterus will have shrunk back to its pre-pregnancy size by six weeks. Physically, she should be able to safely engage in sex without pain. Painful intercourse requires review by the doctor to ascertain and treat the cause.

Apart from the genital tract physical wellness, overall body wellness is also important. As the hormones settle down and the toll of taking care of a newborn comes in, causing chronic fatigue. Some mothers may have battled complications such as high blood pressure, diabetes and anemia during pregnancy that they are still recovering from. Others may have delivered by caesarian section and will be nursing the wounds, both externally and internally.

The mental health state must never be overlooked. Post-partum blues is fairly common though grossly under-diagnosed. This will seriously interfere with the function of the woman as a whole, from the swinging moods, to feelings of inadequacy as a mother or lack of affection for her baby, to sexual hypofunction. In the extreme spectrum of the disease, postpartum psychosis will strongly disable a new mother to the point of needing hospitalization.

Perhaps the psychological state is the most under-appreciated. A positive sexual encounter is heavily dependent on a woman’s psychological state first. Her surrounding environment is vital in determining how she feels. A mother who feels supported and appreciated in her new role, having peace of mind and without social pressure, is more likely to be well adjusted and hence more responsive. However, this may not always be the case. Some mothers may be alone, battling the crying baby with a terrible case of colic, without any help. Others may have an absent spouse or partner to shoulder the responsibility with while others may be worried about financial pressures. With such an unsettled mind, sex is the last thing they want to hear about.

All in all, good health is not only defined as physical but also sexual. It is imperative that after the important journey of bringing forth a new being, the parties that were involved do not suffer loss of this important aspect of their health. It is a component of postpartum care that must not be ignored. It is the pillar upon which contraceptives are discussed and offered. The woman needs to be reassured that it is alright to have a healthy sex life and the partner needs to understand the situation so as to be supportive.

While at it, let us not forget the moms who are not breastfeeding for various reason, their resumption of fertility is much earlier than the breastfeeding moms and they will require contraceptives earlier. There is nothing more traumatic than a mother with a premature baby in the newborn unit finding herself pregnant a few weeks down the line!