From the Delivery Room to the Bedroom

Childbirth can wreak havoc on a couple's intimate relations. Everything that happens during this euphoric yet agonizing event in the delivery room can have lasting effects in the bedroom. To the degree that a woman has any control over the situation, should anticipation of postpartum sexual functioning play a role in her selecting a mode of delivery?

Cesarean sections now make up 30 percent of deliveries in the US, and that number is increasing. Lisa Pastore, an epidemiologist in the University of Virginia's obstetrics and genecology department who recently published a study of postpartum sexuality concerns among first-time parents, says most people who ask for C-sections ask because of scheduling issues or for more control over the situation. But a lot of people don't want to discuss matters of sexuality with their health-care providers. Further, they might not even stop to think that various styles of delivery might have different sexual side effects. In two surveys of obstetricians, a third of doctors say they would choose cesarean sections for themselves. One of their biggest concerns: sex after delivery. Do they know something we don't?

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The C-Section A number of studies in recent years have looked at C-sections and sexual health. One Canadian study published in 2005 showed that three months after childbirth, first-time mothers who had a vaginal birth noted greater sexual dissatisfaction than those who'd had a C-section—70 percent compared with 55 percent. A 2006 study found similar results in women two full years after birth. Another study published in 2005 found long-term differences in the strength of new mothers' pelvic floors—the pelvic muscles and connective tissue supporting the bladder, intestines, and reproductive organs that contract involuntarily during orgasm and can intensify orgasm when contracted voluntarily. More than two years after giving birth, women who'd delivered vaginally had significantly lower pelvic floor muscle strength than those who'd delivered by cesarean section.

A Note on Kegels There are no studies showing that increasing pelvic floor strength directly improves sex because "sexual function is such a complex thing," says Linda Brubaker, a urogynecologist at Loyola University. But we know that pelvic floor exercises such as Kegels decrease incontinence, and we know that women with less incontinence, particularly coital incontinence (leaking of urine during intercourse), have better sex lives. "Feeling comfortable with yourself is key to feeling comfortable within a sexual relationship," Brubaker says, "and fear of incontinence can be a devastating thing for a woman." Further, Brubaker recently finished a study showing that women completing a pelvic fitness course reported improved sexual function, including better orgasm. She says we can't be sure the mediating factor isn't improved social support ("the girls night out effect") instead of stronger muscles or better muscle control, but benefits persisted a year after the end of classes.

Episiotomy One factor that complicates many of the studies comparing vaginal birth with cesarean section is that some women have episiotomies—incisions through the perineum to expand the vaginal opening. This procedure prevents rips, which are hard to repair, and limits stretching of the pelvic floor. In the US, about 30 percent of vaginal births occur with episiotomy. A 2005 JAMA survey of studies found little evidence that women who'd had episiotomies had better pelvic floor function in the months after childbirth. And they took longer to resume intercourse and suffered more pain during sex. How permanent are the effects? In 2008, Swedish scientists reported a study of women's sex lives 12 to 18 months after delivering a first child: Episiotomy-assisted childbirth didn't affect arousal, orgasm, or satisfaction, but did increase the incidence of painful intercourse and dryness. Countering some of the warnings about vaginal birth, the previously mentioned 2005 Canadian study found that women who'd given birth vaginally with an intact perineum actually had less pain during sex than the C-section group after three months. The general consensus is that a safety snip usually causes more harm than it's worth.

Assisted Delivery Another factor is the use of obstetric instruments such as forceps and vacuum. (Again, this is not always up to the mother.) A survey of studies published between 1990 and 2003 concluded that assisted delivery led to painful intercourse, perineal pain, and delays in the resumption of sex.

Men's Concerns Because sexual dysfunction affects both people in a relationship, men should at least be part of these discussions. There are stories of the "husband's knot"—an extra stitch after an episiotomy to create a tighter fit, which benefited the man at the expense of the woman—but this is not currently common practice. However, men may share women's concerns about sex after vaginal birth, as they can feel tension in a their partners' pelvic floor muscles during vaginal intercourse.

Researchers in Turkey recently set out to explore whether men should be concerned about a slack pelvic floor in their partner after delivery. For a study reported in the Journal of Sexual Medicine this year, they had new fathers fill out a sexual satisfaction questionnaire about areas of sexual functioning, including frequency of intercourse, communication, and erectile function. It even asked the question, "Do you ever happen to think your spouse's vagina is so loose that it affects your sexual pleasure?" Their wives had either had an elective cesarean or a vaginal birth with an episiotomy (in Turkey the episiotomy rate is 100 percent.) The bottom line: The guys' complaints had no correlation with mode of delivery. But they can still feel their wife's pain empathetically.

A Room with a View What about the effect of witnessing childbirth on a man's attraction to his partner? For some men, a very intimate body part can become completely desexualized. Or they see someone they cherish dramatically sliced open. In either case, they can then associate their partners with a disturbing and gruesome scene. Occasionally therapists hear cases of lost lust and flashbacks to the Alien movies, but Pastore says male regret is rare. "I think that most men are absolutely thrilled to be in the delivery room and do not find it to be a sexual turnoff." If you can stomach it, get in there and absorb every minute.

The Bottom Line There are lots of factors to consider when planning a delivery, from cosmetic worries (how will I look in a bikini?), to problems with incontinence, to matters of life and death for the mother and child. Among these concerns, sexual health should not be neglected.—Matthew Huston

Four Tips for Improving Postpartum Playtime

  • Before birth: Rub it in. A recent review of studies involving 2,434 women found that perineal massage once or twice a week for the last month of pregnancy reduces the likelihood of perineal trauma (a rip or the need for a cut) among first-time mothers.
  • During birth: Push when you feel like it. Directed pushing refers to pushing and breathing when told to do so. In spontaneous pushing, the woman bears down when she feels the urge. Although spontaneous pushing takes longer, research shows it's more likely to preserve an intact perineum.
  • After birth: Do your exercises. Postpartum Kegels are beneficial, whether after a cesarean section or a vaginal delivery. You'll be more comfortable in bed without the fear of leaking gas or urine, and better control over those pelvic muscles just might intensify orgasm.
  • During sex: Don't rush into it. "Trust your instincts with your own healing," Pastore says. Everyone is different. "The biggest message to give women," she adds, "is to feel free to use vaginal lube and don't feel guilt over it."

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