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6.3 Sexual Function After
Delivery: Postpartum
Sexuality
6.3.1 Denition andCharacteristics
ofPostpartum
Postpartum period, which includes a short and
transient period in the life of a family and an
important milestone in the protection and promotion of the health of the mother, baby, and
family, is a developmental transition period covering the 6-week period after the birth. Although
the days following childbirth are generally considered a period of intense happiness, this period
is a critical phase in the lives of mothers and
newborn babies, family life, and couple relationship [103, 104].
Physiological changes during pregnancy subside in the postpartum period. But all new mothers need time to heal and recover after giving
birth and for the body to recover, cervix to close,
postpartum bleeding to stop, and, if applicable,
their C-section incisions or vaginal tears to heal.
The sudden disappearance of placental hormones
after delivery and the start of lactation cause drastic endocrinological changes in the rst weeks,
but after 6weeks, a steady state is reached. The
psychosocial adaptation of the mother, the baby,
and the family to the new situation usually attains
a new balance. However, this does not mean that
the pre-pregnant state has completely returned,
because lactation usually continues, often the
menstrual cycle has not yet normalized, and sexual activity may not have been resumed yet.
Contraception is an important need in that period,
and it may be problematic for many couples.
Therefore, it is important to support women in
this process, because the lack of social support of
the postpartum woman directly affects the
spouse/marriage relationship and the postpartum
psychology of the woman [103, 104]. Transition
to parenthood can be both extremely pleasurable
and stressful. The relationship within the partners
changes, especially after the birth of a rst child
[37]. After childbirth, numerous physical, psychological, and sociocultural factors may affect
both sexual activity of women and quality of their
lives [10, 11, 105, 106]. In one study, 68% of
women expressed the need for help on postpartum sexual issues [18]. In the WHO’s recommendations, it is emphasized that postpartum male
and female sexuality is as important as many
other conditions that are important in maintaining and improving postpartum health [103, 104].
6.3.2 Resumption ofSexual
Intercourse After Childbirth
The most frequent question in postnatal period is
“when can I restart my sex life?” [62]. Women
can return to sexual activity after birth whenever
they feel they are ready to do so. There is no prescription for the time required to resume sexual
intercourse after birth, because the time required
for resuming sexual intercourse after childbirth
varies from woman to woman and is inuenced
by many factors [27].
In the postpartum period, new parents are concerned about when to resume sexual intercourse,
when to restart birth control, whether or not they
will suffer during sexual intercourse, effect on
sexual activity due to changes between couples,
effect on sexual activity due to body changes,
becoming pregnant again, and similar issues [86,
107]. Many mothers and fathers are afraid to
resume intercourse [29, 108]. One study reported
that 89% of new mothers and 82% of new fathers
had at least one concern related to postpartum
sexuality and approximately 50% of all new parents had multiple postpartum sexual concerns
[107]. Resumption of sexual intercourse after
childbirth is usually possible 6 or 8weeks postpartum [103, 104]. Some studies report that
approximately half (52%) of women resume sexual activity by 5–6weeks postpartum [17, 109],
and this rate is 90% by 3months postpartum [5,
110]. A longitudinal prospective study found that
57% of women at 6weeks, 82% at 12weeks, and
90% at 24weeks resumed intercourse after birth
[111]. One study investigated the time required to
resume sexual intercourse following childbirth in
women with laceration; it was found that women
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with lower grades of laceration (grades I, II)
resumed sexual intercourse on average 7.1weeks
postpartum while women with higher grades of
laceration (grades III, IV) resumed sexual intercourse on average 9.3 weeks postpartum, and
after 6months all women who participated in the
study resumed sexual intercourse regardless of
the level of laceration [108]. In another study, the
percentage of women who resumed having sexual intercourse at 6 months postpartum was
approximately 90%, and the resumption of sexual intercourse took slightly longer for women
with third- and fourth- degree perineal tears [110].
As it is seen in the results of the studies, there
is no standard regarding the time of resumption
of sexual intercourse after birth. The time of
resumption of sexual intercourse after childbirth
varies from individual to individual, from culture
to culture, with the level of experienced changes,
etc.
6.3.3 Factors Aecting Sexuality
During Postpartum
The resumption of postpartum sexual activity is
affected by the numerous changes that occur in a
woman’s anatomy, hormonal status, type of birth,
perineal trauma, episiotomy, breastfeeding,
depression status, partner relationships, family
structure and family dynamics, etc. [86]. In a
study conducted on the factors affecting the sexual activity of women after childbirth, it was
reported that the factors affecting sexual activity
in the rst and second half of the year after childbirth include the concern about pain during intercourse, fatigue, fear of subsequent pregnancy,
tenderness of breasts [11], disinterest, feeling
tired, bleeding, mother diseases, neonate problems, etc. [112]. Lurie et al. mentioned about
three mechanisms that may contribute to postpartum sexual dysfunction: dyspareunia, birth canal
injury, and general maternal health [113].
6.3.3.1 Mode ofDelivery
There are many studies in the literature investigating the effect of mode of delivery on postpartum sexual functions. However, some studies
showed no differences in sexual outcomes
between vaginal delivery and cesarean section
[114], while some studies showed that there are
indirect effects of mode of delivery on sexual
function and sexual satisfaction [115, 116].
According to Saleh’s study, although postnatal
sexual function showed a signicant difference
according to the type of birth, it was reported that
this was not clinically signicant within 1year
after birth [117]. There is no clear evidence in the
literature to support the claim that vaginal births
are harmful and cesarean delivery is protective to
one’s future sexual life [118, 119].
Several studies have shown that primiparity
has a negative impact on subsequent sexual function [120, 121]. However, another study reported
that having more than one child increases the tendency for female sexual dysfunction [122].
According to the study by Makki and Yazdi, dyspareunia decreased in both multipara and primipara, libido decreased in multipara, and vaginal
loosening increased in multipara [123].
It is emphasized that birth (especially vagi-
nal delivery) itself is a risk factor for the development of genito-pelvic dyspareunia in the
postpartum period [124]. Following normal
spontaneous delivery, the vagina is wider and
can be swollen and bruised and the vaginal wall
is poorly lubricated because of hormonal
causes, especially lower levels of estrogen [30].
The mode of vaginal delivery has been reported
to be associated with dyspareunia due to perineal tears, episiotomy, and operative vaginal
delivery [19, 116, 124–126]. One study related
in terms of postpartum sexual desire loss states
that the type of delivery or episiotomy is not the
only factor responsible for the loss of desire
and that other factors may also play a role such
as lack of interest in one’s partner, fear of getting pregnant again, and fear of feeling genital
discomfort [127].
Safarinejad etal. investigated the relationship
between mode of delivery and subsequent incidence of sexual dysfunction, and they found that
the rate of resumed sexual intercourse within
8weeks after delivery was highest in women who
gave birth by planned cesarean section as 64%;
this rate was 42.6% in women who had a sponta-
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neous vaginal delivery (without injuries), and the
lowest rate of 32% was found in those who had
operative vaginal delivery. Also, it is stated that
women who experienced a planned cesarean section had the lowest pain scores, and women who
had operative vaginal delivery had the highest
pain scores at the rst sexual intercourse [128]. In
the same study, it was reported that partners of
women who underwent instrumental delivery
suffered from erectile dysfunction more frequently than partners of women who delivered
vaginally or by cesarean section, but orgasm,
sexual arousal, and sexual satisfaction were not
affected by women’s mode of delivery [128].
One meta-analysis study indicated that cesarean
and spontaneous vaginal delivery did not affect
postpartum sexual satisfaction (short term and
long term) and appeared to have minimal effect
on the long-term resumed intercourse and sexual
pain in primiparous women [129]. One study
reported that resumption of sexual intercourse
did not show a signicant difference according to
the type of birth [19].
The Events Related toVaginal Deliveries
Postpartum sexual behaviors are usually affected
by vaginal delivery events such as assisted vaginal delivery, episiotomy, and perineal damage.
The pelvic oor muscles and disorders: The
pelvic oor is a dynamic unit that allows the
physiology of continence, emptying, sexual function, and delivery [130]. The pelvic oor muscles
play an active part in a woman’s sexual function
[131], and they are also active in both male and
female genital arousal and orgasm [131]. So, pelvic oor disorders are associated with female
sexual disorders, especially also sexual pain disorders [27, 131]. Pelvic oor traumas causing
pelvic oor disorders are especially associated
with advanced maternal age, operative vaginal
delivery, prolonged second stage of labor, fetal
head circumference, position of fetus, episiotomy, nulliparity, use of oxytocin, birth weight
>4kg, etc. [27, 132]. Perineal trauma is a common event in the rst labor, affecting up to 90%
of primigravidas; despite adequate primary
sphincter repair, sexual dysfunction may develop
in most of these patients [132]. Vaginal delivery
is a complex phenomenon involving the activation of several muscles [133]. Episiotomy and
third- and fourth-degree lacerations, which are
effective in perineal oor disorders, may follow
any type of vaginal delivery [132]. Many studies
have found that episiotomy is the factor with the
strongest association with a third- or fourthdegree laceration. As a result, in many studies, it
was indicated that the impaired pelvic oor muscles after birth had negative effects on sexual
functions. One systematic review study reported
that postnatal pelvic oor muscle exercises
(PFME) were effective in improving sexual function [134].
Assisted vaginal deliveries: Assisted vaginal
delivery is sometimes called “instrumental deliv-
ery” or “operative vaginal delivery.” Evidence
suggests a strong link between assisted vaginal
deliveries and impaired sexuality during postpartum [135–138]. Assisted deliveries such as forceps or vacuum are associated with an increased
risk of perineal and anal sphincter trauma, intrapartum pudendal nerve injury resulting in pelvic
oor dysfunction, and sexual health morbidity
[
25, 139–141]. Injuries to pelvic oor muscles
during childbirth, and subsequent repair, can provoke dyspareunia and have effects both on the
time and quality of the reinitiation of postpartum
sexual activity [31, 86, 131, 142–144]. In a systematic review by Hicks etal., it was reported
that increased risks of delay in the resumption of
intercourse, dyspareunia, sexual problems, or
perineal pain were associated with assisted vaginal deliveries [145]. It is stated that long-term
maternal and paternal sexual dysfunction is associated with the highest rate of assisted vaginal
deliveries and the lowest rate of planned cesarean
section [30].
Perineal trauma (lacerations, tears, and
such): Perineal trauma is a common event espe-
cially at the assisted vaginal deliveries (forceps,
vacuum and vaginal breech delivery, and episi-
otomy) [132]. Anatomically, perineal trauma con-
tributes to perineal pain, and perineal pain is the
most common cause of dyspareunia. These are
the most important conditions affecting postpartum sexual function [10, 26, 31, 73, 86, 108,
146–149], affecting both the timing and quality
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of the resumption of sexual relations during the
initial months after delivery [10, 86]. The orgasmic disorders are also inuenced by the presence
of perineal trauma [10, 108]. This is a sequence
of events that affect each other (perineal trauma
causes perineal pain and dyspareunia, and dyspareunia causes postpartum sexual problems and
thus sexual dysfunction).
It is reported that perineal pain occurs in 42%
of women immediately after delivery and reduces
to 22% and 10% at 8 and 12weeks, respectively
[10]. A retrospective cohort study found that
compared to women with an intact perineum,
women with second-degree perineal trauma were
80% more likely to report dyspareunia at
3months postpartum [108]. Studies indicate that
women who delivered with intact perineum were
signicantly more likely to report enhanced sexual functions (sexual sensation, sexual satisfac-
tion, and likelihood of orgasm) [147, 148]. Odar
et al. stated that 22.2% of women had sexual
problems due to vaginal pain (regarding lacera-
tion) at a 6-month postpartum follow-up [150].
There are also very few studies that advocate
the opposite. In one of these studies that compared women with minor or major perineal
trauma after birth, it was reported that both
groups were equally likely to be sexually active
[149]. In another study, there was no relationship
between the postpartum second-degree perineal
lacerations with complaints of urinary or anal
incontinence, sexual inactivity, or sexual function [146].
Episiotomy: During childbirth, some women
suffer spontaneous perineal trauma while others
require episiotomy to facilitate birth. Although
these injuries can be repaired with sutures, such
repairs are frequently associated with perineal
pain and discomfort [151]. It is well known that
episiotomy and repair may have a negative effect
on postpartum sexual activity and may cause dyspareunia [152], and episiotomy is associated with
a higher prevalence of postpartum dyspareunia
[31]. In one study, it was concluded that dyspareunia 3 months after childbirth was common
among rst-time mothers who underwent episiotomy and seemed to be associated with slower
reinitiation of sexual activity [153]. Studies have
shown that women who underwent episiotomy
[110, 154] and women with third- and fourthgrade vaginal tears [108] reported feeling more
pain at 3 and 6months in the postpartum periods.
In addition, some studies reported that not only
pain but also other important aspects of sexual
functions such as arousal, lubrication, orgasm,
and satisfaction were affected [154, 155]. These
results were recently conrmed by Rathsh etal.;
moreover, it is reported that women with episiotomy or a second-degree perineal tear had lower
arousal, orgasm, and sexual satisfaction and more
dyspareunia at 3months after birth [156].
The results of the studies comparing women
with episiotomy and without episiotomy reported
that women with episiotomy had more complaints of perineal pain, dyspareunia, decreased
sexual satisfaction, and delayed resumption and
restoring of sexuality after birth. Based on these
results, it can be said that the restriction of perineal traumas and episiotomy during childbirth is
important for the resumption of subsequent sexual activity.
Cesarean Section
One of the perceived benets of cesarean delivery is sparing the pelvic oor from mechanical
damage. Since the risks of episiotomy or assisted
vaginal birth are eliminated, it will be less likely
to report perineal pain or dyspareunia at cesarean delivery [19, 136, 141, 145], and thereby,
sexual function will be protected. In addition, it
is stated that the somewhat protective role of
cesarean delivery contributes to an early resumption of postpartum sexuality [25, 26, 108]. But a
systematic review showed no differences in sexual function between women with cesarean
delivery and those with spontaneous vaginal
delivery [111, 145].
There are limited studies that specically
evaluate sexual dysfunction in women delivered
by cesarean section. According to the results of
these studies, the rate of postpartum dyspareunia
is low in cesarean deliveries. But it would be
wrong to think that cesarean birth is a precaution
to reduce postpartum dyspareunia. The fact that it
is a major operation with possible serious side
effects should not be ignored.
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6.3.3.2 Breastfeeding
Breastfeeding is also effective on postpartum
sexual activity [103, 104, 157–159]. The physical
as well as psychological aspect of a woman’s
sexuality is altered by breastfeeding [160].
During the rst months (at months 1–4 postpartum), breastfeeding women show less sexual
desire than those who use articial feeding, and
they experience more dyspareunia [26, 103, 104,
161]. Breastfeeding may alter sexual function as
a result of vaginal dryness produced by the high
levels of prolactin and lowered estrogen and
androgen levels [30, 37, 86, 103, 104]. Signorello
etal. stated that women who breastfeed were four
times as likely to report dyspareunia as those who
did not breastfeed [108]. Breastfeeding is linked
to a low coital activity, low sexual desires [26, 31,
157, 161], and low sexual satisfaction of females
and their partners [26, 29, 31, 161, 162].
Resumption of sexuality after birth in breastfeeding women is much later; they more often suffer
from dyspareunia from the sexual intercourse
[31]. One study stated that especially breastfeeding and low partnership quality were revealed as
signicant risk factors for sexual dysfunctional
problems postpartum [163]. On the other hand,
after birth, breasts ceased to be an erotic symbol,
and it became milk-producing and secreting
machines [37]. For both partners, this changed
“meaning” of the breasts may adversely affect
postpartum sexual activities and lower satisfaction. Besides, breastfeeding is tiring and time
consuming with a lot of skin contact, and this can
also reduce the woman’s need for skin contact
with her partner [37].
6.3.3.3 Family Structure, Changing
Sleep Patterns, Fatigue
Although postpartum is a period in which different excitements are experienced, it also has a tiring and stressful side, which changes the family
dynamics, roles, and needs and increases responsibilities. The birth of a baby could disrupt a couple’s balance [27]. Family structure, changing
sleep patterns, and fatigue decrease the likelihood of a woman and her sexual partner having
the time and privacy to re-establish intimacy
[86]. Fatigue and sleeplessness are among the
most commonly reported characteristics of the
postpartum period [103, 104]. They play a
destructive role in satisfying the sexual needs
[37] and inevitably have a negative effect on the
libido [103, 104]. One study indicated that the
fatigue, stress, and perineal pain during the rst
few postpartum months are associated with dyspareunia [164].
6.3.3.4 Postpartum Depression
Most female sexual dysfunctions are multifactorial, and depression is one of these factors. After
delivery, women suffer physical, emotional,
social, nancial, and relational problems that can
worsen over time [27]. Depression and sexual
dysfunction are bidirectional [5, 37]; it begins
generally 2–4 weeks after delivery [165]. In a
population- based study, 40% of depressed
women reported desire, arousal, and orgasm disorders [37].
Although postpartum depression has been
researched extensively, there are limited studies
examining the relationship between sexual health
and depression [166]. One study showed that
cesarean delivery was associated with an
increased prevalence of depressive symptoms at
3months and no differences in the trends related
to depressive symptoms or sexual functions
(except desire) within 1year postpartum [166].
One study found that sexual dysfunction is common in women with postpartum depression and
they are late to resume sexual intercourse after
childbirth [158]. In a cross-sectional study, it was
stated that depressed women were less likely to
have resumed sexual intercourse within 6months
after birth, that their diversity of sexual activities
was low, and that they reported sexual health
problems more than non-depressive women [158,
167]. The psychological condition itself and anti-
depressants used for treatment also affect postpartum sexual functions negatively [168].
Postpartum depression accompanied by loss of
sexual desire or secondary loss of desire, and loss
of arousal or ability to achieve orgasm resulting
from antidepressant medications, may also contribute to postpartum sexual dysfunction [86].
Although postpartum depression resolves, it
sometimes may not improve [165].
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Some factors that may affect female sexual
functions in the postpartum period and their possible effects, and sexual dysfunctions that can be
seen in the postpartum period, are summarized in
Table6.5.
6.3.4 Postpartum Sexual
Dysfunctions
It is almost impossible to say what optimal sexual
function after birth is [30]. Many women experi-
Table 6.5 Some factors and their possible effects on
female sexual functions in the postpartum period
Some factors Possible effects on sexuality
Mode of delivery
• Assisted-operative
vaginal delivery,
episiotomy, perineal
trauma
• Cesarean section
Breastfeeding Less sexual desire
Changing sleep
patterns, fatigue
Postpartum
depression
Sexual dysfunctions that can be seen during
postpartum period
Sexual pain disorders (dyspareunia)
Sexual desire disorders
Arousal and lubrication disorders
Painful orgasm or orgasmic disorder
Sexual satisfaction disorders
Genital discomfort, perineal
pain
Sexual desire loss
Dyspareunia
Delay in the resumption of
intercourse
Sexual problems
Sexual dysfunctions (sexual
pain, arousal and
lubrication, desire, orgasm,
and sexual satisfaction
disorders)
Early resumption of
postpartum sexuality
Less perineal pain or
dyspareunia
Sexual problem reporting is
not much
Decrease in coital activity
Dyspareunia
Less satisfaction
Sexual dysfunctional
problems
Negative effect on the libido
Dyspareunia
Delay in the resumption of
intercourse
Decrease in sexual activity
Sexual dysfunctions (desire,
arousal, and orgasm
disorders)
ence sexual problems in the postpartum period
[10], and this is often overlooked [11, 86]. Given
the data that only 12–14% of couples deny sexual
problems after birth [29, 31], it will give us an
important clue to the extent of the problem.
There are differences in the results of the studies on the prevalence of postpartum female sexual
dysfunction. As well as the literature data indicating that the prevalence of female sexual dysfunction after birth is generally reported as being
between 10 and 40% [169–171], there are also
generally results indicating that the prevalence of
postpartum sexual dysfunction ranges between
22% and 50% [27]. In the 2000s, postpartum sexual dysfunction (including dyspareunia) was
reported in 41–83% of women at 2–3months postpartum [19, 108]. In a different study, the prevalence of female sexual dysfunction after childbirth
has been reported to be 5–35% after the cesarean
section and 40–80% after normal vaginal delivery
[172]. In another study of the same researcher, it
was stated that 64.3% of women experienced sexual dysfunction and 70.5% sexual dissatisfaction
during the rst year after childbirth [120]. More
than one-half of women enjoy sexual intimacy
with their partner in the rst year after giving birth,
with 18–20% partially enjoying it and 24–30% not
enjoying it at all. In addition, their partners have
also reported the same result [29].
It is stated that women reported more than one
sexual disorder in the postpartum period [86].
Most postpartum women may suffer from certain
sexual dysfunctions such as loss of sexual desire
[163], loss of excitation, dyspareunia, vaginal
pain, loss of lubrication, and painful orgasm or
orgasmic disorder [27, 151, 171].
von Sydow stated that postpartum sexual dysfunction is a complex interaction between possible biomedical, psychosocial, and couple
relationship factors as well as the qualities of the
infant and mother-child relationship (Table 6.6)
[29]. Salvatore etal. reported that little is known
about postpartum sexual dysfunction related to
birth, that postpartum sexual dysfunctions are
frequently occurring, and that it is related to various aspects of sexuality. They listed postpartum
female sexual disorders according to their causes
as given in Table6.7 [27].
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Table 6.6
dysfunction
Biomedical factors
Degree of perineal birth trauma (tears, episiotomy)
Assisted vaginal delivery
Tiredness
Kegel exercises not performed
No reliable method of contraception
Psychosocial factors
Mental symptoms (depressed mood, emotional
lability)
Prepregnancy sexual history and sexual symptoms
(e.g., dyspareunia)
Poor childhood relationship with father (e.g., good
relationship only with mother)
Couple/relationship factors
Low relationship satisfaction (in women and men)
Attributes of the baby and the mother-child
relationship
Male babies: mothers of boys are perceived by their
partners as being less tender during the postpartum
months than mothers of girls
Mothers with a rigid and overprotective relationship to
their baby
Breastfeeding
Von Sydow K.Sexuality in pregnancy and the postpartum
period. In: Reece EA, Hobbins JC, eds. Clinical obstetrics:
the fetus and mother. John Wiley & Sons; 2007:
1016–1021
Table 6.7
disorders
• Sexual desire disorders that are often related to the
hypoefciency of the pelvic oor, which occurs
postpartum
• Sexual arousal disorders due to the vaginal dryness
and poor lubrication typical of breastfeeding women
• Orgasmic disorders related to hypotonia due to
childbirth, which causes pain and inability to reach
orgasm
• Supercial dyspareunia (pain during penetration)
Salvatore S, Redaelli A, Baini I, Candiani M. Sexual
Function After Delivery. In: Childbirth-Related Pelvic
Floor Dysfunction. Springer; 2016:101–104
Factors associated with postpartum sexual
Postpartum female sexual dysfunction
A very important determinant of postpartum
sexual function is perineal pain and resultant dyspareunia (painful sexual intercourse) [146, 162,
173]. Sexual pain disorder is the most common
category affecting women in the postpartum
period [47, 173]. More than 50% of all women
experience pain during their rst intercourse after
birth [29, 108]. Dyspareunia, which is one of the
most common sexual problems after birth [10,
27], is quite common in the rst 3–6months after
birth [86]. In studies published in the early 2000s,
dyspareunia is reported to be, respectively, 41%
and 22% at 3 and 6 months postpartum [108].
Barrett et al. also stated that 62% experienced
dyspareunia in the rst 3months postpartum, and
it decreased to 31% at 6months [19]. In a study
carried out by Odar etal., approximately 62% of
women who resumed having sexual intercourse
6 months after childbirth reported pain [150].
Recently, in one article, dyspareunia was reported
by 41–67% of women in 2–3months of postpartum [30]. Dyspareunia is reduced to 22% at
6months postpartum, and it may remain at this
level until 13months postpartum. On the other
hand, postpartum pain has a signicant effect on
sexual satisfaction [29, 108].
It is known that sexual desire is still reduced
1year after giving birth and that the frequency of
sexual intercourse is less [19, 158]. There are
limited studies that specically evaluate sexual
desire disorder in the postpartum period [10].
One study reported that sexual desire disorder in
the perinatal period was the most common form
of female sexual dysfunction [163
]. In a crosssectional study, postpartum loss of sexual desire
was reported to occur in 53% at 3months and
37% at 6months after birth, which is 9% in the
year prior to pregnancy [19].
Sexual arousal, orgasm, and lubrication also
undergo some changes after delivery [27]. The
postpartum period is often associated with a
decline in the couple’s sexual satisfaction [174].
Decreased sexual satisfaction in postpartum
women is not related to the type of birth and is
reported to improve over time [128]. On average,
it is stated that the rst postpartum orgasm may
occur 7weeks after birth, rising to 75% (about
the same as before pregnancy) 3–6months after
the birth [29]. In a cross-sectional study, it was
reported that 33% and 23% of women experienced difculty in reaching orgasm at 3 and
6months postpartum, and 14% of them experienced this problem in the year prior to pregnancy
[19]. It is stated that sexual satisfaction may continue as low in couples also within the rst
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Table 6.8
and treatment of postpartum sexual concerns
Prenatal care
• Determine whether dysfunction was present before
pregnancy
• Discuss changes in anatomy, physiology, and
sexual function that commonly occur during
pregnancy
• Discuss the likely safety of continuing sexual
activity through pregnancy for most women
• Evaluate for the presence of depression during
pregnancy
• Discuss the option of perineal massage to minimize
perineal trauma and postpartum pain
Intrapartum
• Judicious use of operative vaginal delivery and
selection of vacuum rather than forceps will decrease
the incidence of anal sphincter lacerations
• Limit the use of episiotomy
• Careful postpartum examination to increase the
detection and repair of anal sphincter lacerations
• Repair perineal lacerations with synthetic
absorbable suture
• Discuss perineal pain, dyspareunia, and initiation
of postpartum sexual activity before hospital discharge
Postpartum
• Assess sexual function and address concerns,
including considering the use of a brief sexual
function screening questionnaire
• Assess perineal repair if dyspareunia is present
• Assess for the presence of urinary and anal
incontinence symptoms
• Encourage vaginal lubricants, particularly in
breastfeeding women with a physiologic
hypoestrogenic state
• Consider alternative positions
• Assess for postpartum mood changes, adequate
rest, and time for intimacy
Leeman, L.M. and R.G. Rogers, Sex after childbirth:
postpartum sexual function. Obstetrics & Gynecology,
2012. 119(3): p.647–655
Clinical approach in prevention, evaluation,
3years after birth [143, 158]. On the other hand,
in one study, it was reported that the mode of
delivery, breastfeeding, intimacy, and spouse’s
contribution to household chores did not affect
sexual dysfunction [171].
According to Leeman, postpartum sexual dysfunction may be either primary which may indicate lifelong sexual dysfunction or secondary
which indicates a change in function [86]. It is
said that experiencing discomfort with sexual
intercourse is likely to discourage women from
desiring sexual intercourse in subsequent situations and reduce their sexual satisfaction [5].
Suffering from sexual problems can have a detrimental effect on a woman’s quality of life, also
impacting her social, physical, and emotional
well-being [10]. On the other hand, sexual dysfunctions do not involve only women, because
this situation also affects women’s partners [27].
That is why it is important to know the postpartum sexual dysfunctions, assess women and couples in this context, and give counseling.
Maintaining healthy sexual functions of couples during postpartum period will positively
affect their marital relationships, healthy transition to parenting roles, and quality of life. Leeman
and Rogers’ recommendations on the clinical
approach for preventing, evaluating, and treating
postpartum sexual concerns are given in Table6.8
[86].
6.4 Conclusions
Sexual functions in which multifactorial agents
play a role change at some stages of life.
Pregnancy and postpartum periods are two of
them. The evolution of women’s and couples’
sexuality from the pre-pregnant state and pregnancy to postpartum period is a life-changing
event with complex physical, psychological, and
sociocultural agents. Pregnancy and postpartum
processes, which play a temporary but also very
important role in the life of women and couples,
cause signicant changes in the sexual life of
women and couples. Therefore, sexual health
counseling is important in preconceptional, pregnancy, and postpartum processes.
6.5 Recommendations
Pregnancy and postpartum sexual health is a
common concern that is often not discussed and
overlooked during prenatal or postpartum care,
and it has received little attention from healthcare
providers. However, preserving healthy sexual
functions during pregnancy and the postpartum
period is crucial, not only for improving the quality of sexual life of women but also for healthy
sex life of couples. Therefore, care in preconcep-
6 Sexuality During andAfter Pregnancy
https://t.me/medicina_free
117
tional, prenatal, and postnatal follow- ups should
also be structured to include sexual health assessment, sex education, and counseling. In the evaluation of sexual functions, it must be determined
whether the sexual problem is a situational problem due to changes in the current periods, or it is
a continuing sexual problem that has existed in
the past. An elaborated sexual history is a cornerstone of all sexual problem assessments and sexual dysfunction diagnoses. The use of scales or
questionnaires can play a key role in the diagnostic evaluation of sexual dysfunctions. Also, the
scales may help in providing coherent and evidence-based management for sexual dysfunctions. There are many scales or questionnaires
that can be benecial in the evaluation of female
sexual functions. For example, “Female Sexual
Function Index (FSFI),” “Sexual Function
Questionnaire (SFQ),” “Female Sexual Distress
Scale-Revised (FSDS-R),” “The Brief Sexual
Symptom Checklist (BSSC),” Golombok Rust
Inventory of Sexual Satisfaction (GRISS), Index
of Female Sexual Function (IFSF), and the Carol
Postpartum Sexual Function and Dyspareunia
Assessment Scale are some of such scales and
questionnaires that can be used for the diagnostic
evaluation of sexual dysfunction, sexual problems, or sexual function status in women.
Moreover, women and couples should be encouraged to talk and discuss about sex-related issues
during pregnancy and postpartum periods. Sexual
health counseling should be done. Sexual function needs to be addressed as part of holistic care
of the pregnant and postpartum woman and couple, and offered care should be evidence based,
qualitative, and sensitive. In order for these to be
implemented, health professionals should have
the awareness, knowledge, and skills to deal with
these sexual problems.
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