Reproduced from "Nursing in General Practice", the Journal of the Irish Nurses Association (Issue 1, Volume 3)
Author: Kate McCabe
A study in the Journal of Clinical Nursing showed that postnatal sexual problems can persist for lengthy periods and affect a surprisingly large number of women. The report suggests that nearly one-in-three women still experience painful intercourse a year after their baby is born and more than half have at least one sex-related health problem.
Some 482 women who had attended maternity units in Birmingham, UK, took part in a self-administered questionnaire at least one year after their most recent birth. "Eighty seven percent complained of at least one health problem," said midwife Amanda Williamns. "Asian women, who made up 15% of the survey, were more likely to complain of health problems than white women, as were white women who were older and had larger babies and longer labours." She identified the three most common problems:
- Sex-related health issues (55%)
- Stress urinary incontinence (54%)
- Urge urinary incontinence (37%)
Painful intercourse was reported by 19% of women who had caesareans, 34% who had a normal birth and 36% of women who had an instrument-assisted birth, such as forceps.
Sex-related problems were highest among instrument-assisted births (77%) and lowest among caerarean births (51%), with 64% of women having had normal births reporting at least one problem relating to sex.
Women who had an instrument-assisted delivery also took two weeks longer than women who had had caesareans and normal births to to resume sexual intercourse (ten weeks versus eight) with figures ranging from one week to 52.
Problems with forceps delivery
Forceps deliveries were also associated with higher levels of stress, urge, and continual incontinence.
Having an epidural did not lead to an overall increase in health problems and this study did not support previous research that identified increased stress incontinence and freequent urinating as risk factors.
Asian women reported greater health problems than white women. Perineal pain was more than 2 times higher (62% versus 28%) and they experienced much higher levels of continual urinary incontinence (35% versus 20%). However, Afro-Caribbean women displayed similar levels of ill health to white women.
The women surveyed were aged 16 or over and from all ethnic groups. They had had their babies at least 12 months before the survey began and all had a live baby with no congenital abnormalities at the time of survey.
"Our research has raised a number of issues", says Amanda Williams. "For example, it has highlighted concerns about the long-term health effects resulting from forceps deliveries and the variations in ill health between white and Asian women. Both these areas could benefit from further research."
"It's also important to point out that while women who had had caesareans reported fewer problems with the healkth issues covered by this study, this delivery method is associated with other problems that have a negative effect on women's quality of life, such as adhesions and wound infections."
"We believe that our study points to the need for health professionals to provide ongoing support for women who have given birth, focusing on issues such as perineal problems and sensitive health problems. This, coupled with greater public aware ness of these issues, will hopefully make it easier for women to get help for both short-trem and long-term health problems," says Amanda Williams.
Factors influencing women's emotions post childbirth
- Episiotomy or a repaired vaginal tear may take several months to heal completely. Even without an episiotomy or a tear, the perineal area (between the vagina and anus) can feel bruised and sensitive for some time.
- Vagina may lack natural lubrication due to low levels of oestrogen following childbirth.
- Oestrogen levels may also remain low when breast-feeding.
- Trauma: having a baby pass through the vagina can be a traumatic process for some women. Difficult or complicated births can cause severe trauma.
- Vagina discharge that smells unpleasant could indicate an infection that requires medical attention.
- Low libido: many women say that their libido is low at this time - they just don't feel sexy.
- Hormonal changes.
- Body image - a woman's body may feel so significantly changed by the processes of pregnancy and childbirth leading to a feeling that she needs time to recover and feel like herself again.
- The shape and sensitivity of the vagina may have changed.
- Anxiety about her new baby and the new world of motherhood.
- Distractions, such as a crying or unsettled baby.
- Life is different: even with an uncomplicated birth of a much wanted child, life is much more demanding for everyone in the household, especially the new mother. Tiredness is an overwhelming factor.
Looking after a baby 24 hours a day is exhausting physically and emotionally, so when the mother gets into bed she may just want to sleep. This is clearly what nature demands - it ensures that the baby is well looked after. It takes priority and may not leave much time for the mother or her partner.
Role of practice nurse
- Raise awareness
- Give information
- Normalising: There is a vital educational component here. Factual information can be very helpful and very empowering for women and their partners. It also serves to debunk some myths and preconceptions e.g. that everything returns to normal after the mother has had her six weeks postnatal check-up and sexual relations may resume as normal. This kind of information is as important as the other routine health information that she will be given childbirth. It is most important to help 'normalise' what women are experiencing and to make them feel listened to and understood.
- All mothers and their partners need information about sex after childbirth.
- Both partners should be aware of, and know how to cope with, vaginal changes.
- Both partners need to know and understand the reasons why intercourse may be uncomfortable.
- Both partners should be aware that there are no hard and fast rules about when desire and comfort for sex will return or when to resume sexual relations. It varies significantly for each women. The parents should be encouraged to look at other ways to show their love for each other. Lubricants like K-Y Jelly, Liquid Silk or Pjur may help to overcome vaginal dryness. It's important to advise couples that it's not recommended that the man perform oral sex on the woman for the first two or three months after childbirth, for the following reasons:
- If she hasn't healed completely (internally and externally), there is a risk that it could introduce infection into the vagina and womb.
- It rarely happens but it can lead to dealth. Air blown into the vagina can easily get into the blood vessels of the newly delivered womb and cause a fatal-illness called 'air embolism'. Not long ago one such death was reported in the British press.
With commonsense advice, a loving couple can usually get things sorted out - though it may take some months. New parents should be encouraged to take advantage of any offers of babysitting that come from family and friends so that they can go out together or even grab a few moments to be loving and close with each other. Mothers should be encouraged to meet other mothers to chat, share experiences, exchange information and build up social contacts.
Time is a factor for medical personnel but taking a proactive role in spotting mothers with potential problems would help to get them the care and support they need.
Awareness raising is important so that women realise that they can get help, thus preventing long-term sexual problems developing. Women should be encouraged woment to use their GP, practice nurse and public health nurse. The GP will check if there are medical problems that are contributing to the difficulties.
If medical problems are ruled out, the woman and her partner should be given the opportunity to familiarise themselves with the advice and help available through pyschosexual therapy services.
An ideal opportunity to provide information to mothers and their partners is during antenatal classes rather than the postnatal period when adaptation to parenthood takes up their entire energy and involves profound change in their lives. This would give them an opportunity to familiarise themselves with information, clarify any queries and ask any questions they might have. Equally important, it would give them the opportunity to discuss together how they as a couple will manage the changes and challenges of parenthood while keeping intimacy at the core of their relationship.
Briefly, psychosexual therapy offers help for people with sexual problems. Some sexual problems are purely physical and some are purely psychological. Many are a combination of both. Psychosexual therapists are trained counsellors or medical professionals who have undertaken special training to deal with issues associated with sexual functioning. It's not a newfangled idea it has been in use for well over forty years. Most referrals come from counsellors, GPs and other medical professionals. Self-referrals are also welcome. Although the likelihood that someone will consult a psychosexual therapist has increased, many people still find it difficult to talk about sex.
A woman may feel vulnerable and fragile post childbirth - a warm caring supportive encironment is important to that she and her partner can build a comfort level to talk about their difficulties. They both need to be assured that these problems are normal, treatable and that they don't have to live with them for the rest of their lives.
Initially, the therapist will explain the process, give the couple an opportunity to familiarise themselves with alternative ways of addressing problems, clarify any issues and ask any questions they may have.
The therapist will then get information about the sexual problem and if she / he thinks that they could benefit from pyschosexual therapy, an individual treatment plan will be prepared to suit their individual needs.
Both partners are encouraged to attend sessions, but a woman can attend and benefit from the treatment plan as an individual. Attendance at sessions and the material discussed is confidential.
Those who decide that a programme may suit their needs will set their own goals at the beginning of therapy and will work at their own pace until they are happy with what they have achieved.
There is no physical examination and work assigned takes place in the privacy of one's own home.
Nearly one in three women still experience painful sexual intercourse a year after their baby is born and more than half have at least one sex related problem, according to research.
Some recovery time is to be expected. Adjustment to recovery and healing involves a process that does not follow a set timetable with a specific deadline.
If problems persist, it is important to encourage the couple to talk to a professional - practice nurse, GP, PHN or psychosexual therapist. Antental classes are an ideal opportunity to raise awareness, normalise and give information to mothers and their partners.
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