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Sex and Pregnancy: Teaching our Students …What’s Important to Know

Childbirth educators should be able to discuss sex during pregnancy and sex in the postpartum period with sensitive, evidence-based counseling, so that women need not rely on anecdotal information, old-wives tales or unreliable sources.

The following quote stands as introduction to the chapter on “Sexuality in the Prenatal Period” in Childbirth Education: Practice, Research and Theory:

Childbirth educators, in their evolving role to meet the needs of twenty-first century prenatal couples, must perceive themselves as more than educators.  They must judiciously add counseling skills to their repertoire of classroom strategies.”1

 

They should “approach pregnancy as a time of  heightened feelings in which physical contact and affectionate behaviors are particularly important for the pregnant  couple”2,  teaching from a strong “knowledge base”3  but those recommendations may be difficult to implement  when discussing  sex during  and  after pregnancy.  Clinicians have reported that sexuality is a difficult subject to discuss and some even question the appropriateness of any discussion of sex with their clients4.  Therefore, guidance, advice and the counseling of pregnant women by childbirth educators about sex is bound to be a tricky task.

I’ve brought up this aspect of our teaching with several CB educators, and have heard the opinion that discussing sex during pregnancy should not be in our purview, that it did seem integral to touch briefly on sex and contraception after birth, but in the main, they felt that the subject of sex was of small importance in our teaching, what with all the other information for which we are responsible.  The Official Lamaze Guide  devotes a mere half-page to information  about sex during pregnancy and only a short paragraph more  about postpartum sex.  In the 2010 edition of the Debby Amis and Jeanne Green Prepared Childbirth, the Family Way, there are two sentences about having sex before birth, confined to a chart on the progression of a pregnancy, and a few sentences about sex postpartum; both books give virtually no importance to the subject.

For those of us who do allocate class time for this subject, there is some very good advice and counsel in Midwifery: Community-Based Care during the Childbirth Year.  Most of us will find the advice properly helpful, sensitive and conservative: obtain permission to discuss the subject, offer concise, simple and basic facts when introducing the subject, make specific suggestions, illustrate with good visuals, and invite women to share experiences with a question like,

 

Some women have told me that their sex life changes a lot when they are pregnant…what has it been like for you?”

 

The text also recommends that clinicians, and I suggest, childbirth educators, become knowledgeable about lesbian pregnancy-and-parenting as well.   While there seems to be little research specific to lesbian pregnancy and that family dynamic, it is a contemporary issue, and I submit that it deserves further thought and discussion as we pursue parity and equity for women. This forum might indeed be a good place to start the conversation.

A woman’s feelings about sex may, of course, change during pregnancy for a multitude of reasons, some physical, some emotional and some spiritual. Her partner’s feelings are subject to change as well, even though sexual intercourse during pregnancy is generally fine for healthy women with healthy pregnancies and will not harm the baby.  Nonetheless, women/couples may experience changes in physical and emotional comfort and desire as the pregnancy progresses.

As for the bare physiological facts surrounding sex during pregnancy, there is general consensus in the medical profession about what sexual behaviors are safe and which ones may be harmful, with agreement to be found across the range of medical organizations and prestigious journals.   As example of the continuing and prevailing view, there is a “new, evidence-based primer to assist physicians in counseling patients regarding sexual activity during pregnancy.”  It was published online, on January 31, 2011 in the Canadian Medical Association Journal.6 The primer joins all the other expert opinions that have been telling women essentially the same thing for the last twenty years… that sex during pregnancy is safe in most instances. However, intercourse should be avoided where the following apply: history of miscarriage, history of preterm labor/birth, unexplained vaginal bleeding or discharge of fluids, low-lying placenta or placenta previa, incompetent or dilated cervix, and multiples in utero. Women should avoid having sex when a partner has a sexually transmissible infection in all circumstances. Oral sex is ok as long as a partner does not blow air into the vagina because of the risk of air embolism.

The conventional opinions, ranging from that in the pregnancy book published by the Mayo clinic, to the “cool” website AskMen.com, are all in accord about the facts of sex during pregnancy, mixing what the aforementioned childbirth education text calls  “the unmixable”…  that of mother and lover7.  The AskMen site says with good humor,  “Luckily you can have lots and lots of sex as long as she’s game and doesn’t have any special medical complications.”8

Most women don’t really think in advance about the first couple of months after the birth of their babies with any awareness of the huge physical and emotional changes that birth brings.  There will be new physical stressors like the genuine exhaustion that comes from being the 24/7 caregiver of a newborn, and other demands of parenthood.  This is where childbirth educators may give some anticipatory guidance with a discussion of postpartum contraception, information about the behavior of the newborn in the first weeks after birth, and extend the invitation to discuss facts about resuming sex.  It is common for most women to be told by their caregivers that they can resume having sex about six weeks after the birth, depending of course, on whether their bodies have healed and whether they want do so. The six-week time line usually coincides with a woman’s first postpartum check-up after a vaginal birth, so she can base her decision about resuming sex at least in part on a physical evaluation.  This time-frame may be too stringent for the woman who has had an uneventful birth, with little or no trauma to her birthing body, and the one-size-fits-all prescription to wait six weeks can be set aside; she should be encouraged to resume having sex whenever she feels ready.  Ideally, we hope that a woman will be able to make decisions about her intimate relationship during and after her pregnancy with a loving partner, based on accurate and supportive information.

As promoters and supporters of breastfeeding, Lamaze educators must make themselves knowledgeable about contraceptive methods that don’t have a negative impact on breastfeeding.  The natural infertility conferred by lactation can be very brief, between three and six months or less, and depends upon total and exclusive breastfeeding with nursing frequency at least six times in 24 hours. Depending solely on exclusive breastfeeding for contraception is known as LAM, the Lactation Menorrhea Method. To be sure to prevent unwanted pregnancy, contraception should commence when women resume having sex. The hierarchy of contraceptive methods for nursing mothers begins with barrier methods as first choice…condoms, diaphragms (for which women need to be refitted after the birth of their babies), and spermicides and other non-hormonal methods.  Hormonal contraceptives should be progestin-only, but are considered to be a second choice. We hope that women will get evidence-based advice from their caregivers about contraception, but  we should, nonetheless, be prepared to discuss the topic. As in every other phase of women’s’ reproductive lives, informed choice based on accurate information is the ideal.

Posted by: Jackie Levine, LCCE, FACCE, CD(DONA), CLC

 

References:

1-Childbirth Education: Practice, Research and Theory, Francine H. Nichols and Sharron Smith Humenick, p49, 2nd edition, WB Saunders, 2000

2-Ibid p.64

3-Ibid p.62

4-Warner PH, Rowe T, Whipple B: Shedding light on the sexual history, American Journal of Nursing 99(6):34-40, 1999.       

5-Midwifery: Community-Based Care during the Childbirth Year, Linda V Walsh, p180 WB Saunders Company, 2001.

6- http://www.medscape.org/viewarticle/736791

7-Childbirth Education: Practice, Research and Theory, Francine H. Nichols and Sharron Smith Humenick, p62 2nd edition, WB Saunders, 2000

8-www.askmen.com/dating/love_tip_250/259b_love_tip.html

 

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  1. August 11th, 2011 at 18:06 | #1

    Jackie – the co-founder of Lamaze, Elisabeth Bing wrote a whole book: Making Love During Pregnancy. It’s out of print now but it was published in the 80′s, a more conservative time than now.
    It would be worth finding a copy to read.

  2. avatar
    Jackie Levine
    August 11th, 2011 at 18:25 | #2

    I thank you greatly for that information, and I agree, it would surely be a worthwhile book to own. I had no idea that she’d written such a book, although I own others that she’s written. I feel very connected to her, although we haven’t spoken in many years. When I was having my three Lamaze babies in the ’60s, Eizabeth Bing and I spent alot of time on the phone. I will certainly try to get hold of a copy to add to my library. Does she recommend that we spend time on that subject in our classes? Again, I thank you for the information. Off I go to find it if I can.

  3. August 11th, 2011 at 20:01 | #3

    I agree with you that sex during pregnancy and post partum is a topic childbirth educators should be knowledgeable about and feel comfortable discussing. Just last night in my Early Pregnancy class we had an interesting discussion on the subject, and I certainly bring it up in postpartum discussions as well. Some groups are far more open to and accepting of this subject than others.  I also agree with you that one should “obtain permission to discuss the subject, offer concise, simple and basic facts when introducing the subject…”. Please realize that “Prepared Childbirth – The Family Way” is written to be acceptable to many cultures, groups, hospitals, and individuals internationally. We intend that it not be offensive to any of our readers. We have no way of “obtaining permission to discuss the subject” if it is written in our book. Perhaps it would be appropriate to refer them to articles in the WebIt! section on our website. We will consider this. We have attempted only to introduce the subject and rely on the educators who use our book to teach at a level appropriate to the groups they teach regarding contraception and sexual practices. Our book is intended to complement the educator and the class, not to stand alone as a text. The information you share is good for educators to know. But do “all expert opinions” really say that mothers carrying multiples shouldn’t have intercourse at all?? Saying that will make me unpopular with some of the couples I teach! :) Thanks for bringing up the subject, but please understand why we don’t include more information in “Prepared Childbirth – The Family Way.”

  4. August 12th, 2011 at 08:38 | #4

    Thanks for writing on this topic! So ironic that we educate people about childbirth but can leave out the fun stuff. In my Lamaze classes we talk about sex as a way to get things started with birth, with the usual caveats about letting our babies and bodies begin birth, etc. (My classes center on Lamaze’s 6 Healthy Birth practices.) And I’m specific — penis/vag intercourse with semen on the cervix, and the woman having an orgasm would probably help a few contractions get going, too. I’d love to know if/how other educators talk about sex after birth. We go over how KY/Astroglide is our friend, and how the partner doing housework is really sexy, among other things. I love the latch idea that someone shared on facebook. And I love the prepared childbirth book, too. Wish i could combine it, Lamaze’s book, and Simkin’s book! Thanks for the column!

  5. avatar
    Jackie Levine
    August 12th, 2011 at 10:03 | #5

    To Jeanne and others: I surely did not mean to point to “Prepared Childbirth-The Family Way” or to “The Official Lamaze Guide” for that matter, as being insufficient, less valuable or remiss in that they lacked information, or to suggest that these books were intentionally ignoring the subject to make less of its importance. I meant only to point out that the subject was one that was pretty much off the radar in “official” publications and not a part of the standard curriculum; choices must always be made so that the audience may be well-served.

    Individual educators, in their diversity and creativity, will expand on a subject as the need arises, or pursue a thread not based on curriculum as much as on intuition and experience in response to the needs of a class. Of this I am certain! In writing the post, I had the same kind of choices to make; with much information to share, I chose to shape the subject in mere outline, rather than wind up with a piece that would require the installment plan, but with the hope that it would just give us a heads-up and a think.

    Lucy, your enthusiasm for the subject is a delight, and it’s easy to imagine that your classes are fun-filled. And Jeanne, I gleaned the proscription against sex if a woman is carrying multiples as the general consensus of the studies and anecdotal information I came across, but it was pointed mostly at the third trimester. As in much of maternity care, there are few standard, evidence based practice guidelines, (as I repeat so often, only 23% or so of practices are based on Level A evidence, and individual caregivers will be more or less conservative, so I mentioned that as briefly as I could manage. I thank you both for your good words.

  6. August 12th, 2011 at 11:36 | #6

    I generally love this website, but I have to say that I’m very disappointed with this article.

    As has previously been mentioned, there is that question about sex with multiples. Must women who are pregnant with multiples really abstain throughout their pregnancies? I also thought the whole “air blowing” thing has been recently acknowledged to not be evidenced based.

    Further, I was really hoping to get some evidence based guidelines on post-partum sex from this article. Specifically, I was hoping for a clear recognition that the common 6 week waiting period is not evidence based, but rather is suggested perhaps out of a mix of tradition (40 day waiting period in Judeo/Christian tradition) and in an attempt to allow the care provider to counsel the woman on birth control at her 6 week visit before she resumes intercourse.

    The OB I used for the birth of my second daughter 11 years ago told me that at least 30% of his clients admitted to engaging in intercourse prior to their 6 week visit, and he was okay with that, he interpretted it as an indication that they were healing well. But that did leave me wondering just how long does a woman really need to wait? I have had good births, and generally within a few days after birth I find myself feeling rather amorous and pleased with the sudden weight loss. I will admit that I’ve had intercourse as early as 6 days post-partum because it was Valentine’s Day. I’m sure we’ve all heard tales (urban legend?) of the couples who are caught in an intimate embrace in their post-partum hospital room. I do wonder what real risk there is to this? I’ve heard a suggestion that an infection may develop at the placental attachment site, so I used a condom as a barrier. But would an infection really happen? I can’t find any research evidence supporting it.

    I also question the heirarchy of birth control methods as presented. LAM (which is Lactation Amenorrhea Method, not Lactational Menorrhea Method) involves more than just nursing 6 times per day. It involves not introducing artificial nipples and not allowing a period of more than 6 hours without nursing, as well as some other rules that are detailed more at resources such as http://www.breastfeeding.com/reading_room/lam.html. This method, while mentioned, doesn’t even really seem to be placed in your heirachy despite its high effectiveness. Why are condoms and diaphragms listed first when they have up to 20% failure rates? To be sure I’m not a fan of hormonal birth control becuase of their impact on body functions and because they can cause early abortions, but women should be cautioned about the high failure rates of barrier methods and encouraged to combine methods to increase effectiveness.

    Truly I think there is not a lot of good evidence on what sexual practices are medically acceptable at various stages in the perinatal period…and so the “advice” we give out is based more on tradition and conveniance than anything else.

  7. avatar
    Jackie Levine
    August 12th, 2011 at 20:45 | #7

    Let me commend you first for your keen eye… of course its Amenorrhea, since otherwise the initials couldn’t have the “A” in the middle and the word loses its meaning. Typos abound when I type..…but it does seem to be LactationAL, as per the link to the site you recommended and Ruth Lawrence’s breast feeding textbooks.

    While I surely didn’t want to disappoint, your complaints are valid. There is little evidence-based info specific to the 6-week waiting period. Your analysis of the reason for that 6-week period sounds right on, and as I also said, gives the OB a look at how things are going. I think that women should be seen sooner than six weeks, but that’s not about to happen, and OBs are playing it safe. You say that you had hoped to get some “evidence-based guidelines from this article” about post partum sex, but even your own experience with your birth 11 years ago left you with info from your doc that was equivocal. When he told you about the 30% of clients, did he warn you not to be one of them? If not, he was sending you the signal that it was OK. OBs will give you guidelines, and there are no police coming to get you if you choose to do what is right for you. There will surely be those among us for whom the expression of ardent and loving feelings is worth some discomfort. You are living proof that sex soon after birth is fine. But I’ve had clients whose episiotomies caused pain and distress during sex 6 months after birth.

    As I’ve said…evidence-based information is the coin of the realm, but it doesn’t always exist as Level A where this topic is concerned. One OB text, ”Obstetrics: Normal and Problem Pregnancies, 3rd ed, Gabbe, Niebyl and Simpson ” (Churchill Livingstone Press) says “Sexual activity may be resumed when the perineum is comfortable and when bleeding has diminished. The desire and willingness to resume sexual activity in the puerperium varies greatly among women because …etc.”, and you can imagine the rest of that unspecific short paragraph. That’s the info for the doc reading this text. That’s all. And it’s a book of more than 1300 pages. It seems that stuff like resuming sexual relations is way less important to the OB than things like the sequelae of birth asphyxia, to which are devoted two full pages of text. But the midwifery text that I mention in my post gives more or less the self-same advice to the midwife. There is the need to let tissues heal, and the need for libido to assert itself. That just makes sense. My words were that “it is common for women to be told” to wait six weeks. Whether they commonly ignore that info is not clear. There are risks of infection if any lacerated tissue comes in contact with bacteria, but as for the site of placental attachment becoming infected in the weeks after birth just from intercourse? I am going to ask some docs about their experiences. The uterus clamps down and shrinks pretty quickly. And while I’m sure that there have been many cases of intimate behavior in the recovery room, I wonder if couples would want to experience real penetration in the hours immediately after the birth. I hope to get some good answers about air embolism blocking blood flow.
    As for abstaining when carrying multiples, I should have put a finer point on it by saying that OBs advise abstinence in the third trimester. Since multiple pregnancies are riskier, the common sense approach makes docs want mothers to err on the side of safety.

    Successful LAM has to do with the steady and continual stimulation of prolactin via stim of the breast; prolactin is antithetical to the hormones of ovulation, so stimulation of the breast by hand expression and pumping can have the same effect. You sound angry that I didn’t “even really seem to be [placing it} in [the] hierarchy…”etc. I did not decide on that hierarchy. That hierarchy is based on human biology with total abstinence as the first suggestion, and is structured that way I listed it in every breastfeeding text and breast feeding course as well as the website that you linked us to; while LAM is effective for some, it only lasts for about 6 months and, unlike a barrier, it can be subject to unforeseen circumstances that may cause the mother to have to quit breast stimulation for a short period. After many months of not having had to worry about getting pregnant, the new mother is back among the worriers if she has resumed relations. I can’t imagine that she will turn a blind eye to the pros and cons of each method as she discusses it with her caregiver and/or her partner. We are talking about informed choices here, and anyone who has read my piece, and never had any idea about contraception, can hardly believe that I’ve recommended one or the other, or am against combining methods that a woman may find acceptable to her status as a new mother.

    As Lamaze educators, we are not charged with making this subject part of our teaching, but I think we do try to give good info and don’t just base it on “convenience”. I hope that I’ve done a decent job answering your complaints and was able to clarify my position for you. As I said in the post, getting knowledgeable and being able to counsel about sex/pregnancy/birth is a tricky thing.

  8. August 13th, 2011 at 11:21 | #8

    Jackie – Lamaze does have a list of recommended topics for a childbirth class and “emotional changes and sexuality” is one of the listed topics. When participants in our Passion for Birth workshop create their topic flow for their course designs, they use this list as the backbone of their plan. The list is on the Lamaze website.
    I agree with you that sexuality should be covered.

  9. avatar
    Walker Karraa, MFA, MA, CD
    August 13th, 2011 at 11:58 | #9

    And I am wondering…as I am unfamiliar with the curriculum for “emotional changes and sexuality”–is there education regarding mood disorders?

  10. August 13th, 2011 at 12:07 | #10

    yes – it’s on the list as well.

  11. avatar
    Jackie Levine
    August 13th, 2011 at 14:36 | #11

    I thank you Teri for telling me what I surely should know. I admit and of course now regret not having been to the website for that kind of info for waaay too long.

  12. avatar
    Walker Karraa, MFA, MA, CD
    August 13th, 2011 at 15:38 | #12

    would you share what that is? it would be most helpful.
    @Teri Shilling

  13. avatar
    Walker Karraa, MFA, MA, CD
    August 13th, 2011 at 15:41 | #13

    Dear Jackie,
    So many of these issues and comments would be covered in preconception and interconception care/education discussed by Michael Lu, MD. This is an exact example of what he talked about all week in those interviews here at S&S–why don’t people see that connection? It astonishes me.

  14. August 14th, 2011 at 01:18 | #14

    Hi Jackie and all
    Thankyou for this discussion.
    I wonder how much support childbirth educators would give the position that “To be sure to prevent unwanted pregnancy, contraception should commence when women resume having sex.”
    I have to disagree. (No contraceptive method is 100% reliable.)
    I have understood for the past decade or so that the evidence supports LAM as being at least as reliable as other methods (other than abstinance).
    I am happy to direct women in my care to information on LAM, as described by Miriam Labbok and others. The three key points to remember in LAM are baby less than 6 months old, exclusive breastfeeding, and amenorrhoea. Of course we can worry about the ovulation prior to the first menstrual period, when baby has a long sleep at night, and if that’s the concern, other contraceptive measures can be employed. Many mothers who practise closely bonded mothering, with free access of baby to the breast, find that their amenorrhoea (and infertility) continues well beyond the baby’s first year.

  15. August 14th, 2011 at 08:48 | #15

    @Joy Johnston
    Joy, this may be generally true, but is not true for all women, so any suggestions of LAM should come with that caveat. I exclusively breastfed both my boys “on demand”, co-sleeping, with them not nursing every few hours through the night for at least a few months, and I got my period back at 6 weeks pp w/#1 and 4 weeks pp w/#2. However, w/#2, I did start pumping milk for a friend’s adopted baby around 3-4 weeks pp and built up my pumping to about 25 oz. per day in addition to exclusively breastfeeding my younger son, and I skipped my second period at 8 weeks, but was regular beyond that (although I did stop pumping after 6 weeks). So, maybe for me, if I breastfed twins or triplets I’d have success with LAM, but so far I haven’t with a singleton, so don’t consider it a safe method of contraception, even though I know that most women would.

  16. August 14th, 2011 at 10:00 | #16

    @Walker Karraa, MFA, MA, CD
    I’m not sure what you want me to share? Lamaze has a list of recommended topics for a childbirth class. As a Lamaze accredited program we use those topics to help new educators create their course design. The list includes:
    * Pregnancy: Emotional changes and sexuality
    (depression/abuse)
    * Postpartum emotions
    (exhaustion, blues, depression and
    beyond)
    I will let Lamaze staff respond as to where the list is on the Lamaze website.

  17. August 14th, 2011 at 12:26 | #17

    @Teri Shilling
    I didn’t mean to sound snippy – I am just not sure where on the Lamaze website the list is….I know it’s there somewhere.

  18. avatar
    Jackie Levine
    August 14th, 2011 at 13:24 | #18

    Joy, of course you are right; no method is foolproof. I should choose my words very carefully so as not to mislead you or others. Perhaps I should have said: “To prevent unwanted pregnancy as much is as humanly possible, it makes sense for contraception to begin when women resume having sex, but caregivers and counselors must warn all users of contraception to be aware that any and all methods have a failure rate, however small; some failure may be due to the product itself, some failure may be due to human error or method failures may be due to some combination of both. Partners should be sure to ask caregivers about every nuance of the use of each method so as to negate error as well as they can. No method aside from total abstinence is foolproof.”? I hope that this amendment clears up any ambiguity or barrier to perfect clarity that you found in that sentence of mine. I agree that LAM can be an ideal method. Perhaps someone will develop a cheap, easy immediate and foolproof test to let a woman know whether she’s ovulating or is about to do so… something like the home pregnancy test. The methods we have to indicate ovulation just aren’t easy enough as they stand now. But thanks for the heads-up so I could clarify things.

  19. avatar
    Jackie Levine
    August 14th, 2011 at 14:08 | #19

    @Walker Karraa, MFA, MA, CD
    Yes, Walker, it is all there in those illuminating interviews. Thanks for jumping in with that.

  20. September 4th, 2011 at 11:25 | #20

    I am re-reading portions of the 2000 edition of Childbirth Education: Practice, Research, and Theory (Nichols and Humenick)for other purposes, and note that Chapter 4 is Sexuality in the Perinatal Period by Norma Neahr Wilkerson and Pamela Shrock. It is a good resource for educators wanting to be more knowledgeable about this subject. If you haven’t read it, or haven’t read it in a long time, you might benefit from pulling this book out again.

  21. avatar
    Jacqueline Levine
    September 5th, 2011 at 10:12 | #21

    @Jeanne Green
    Thanks for pointing that out…I began this post with a quote from that very chapter, and I surely should have continued with a recommendation for it, as you have done. The chapter is better than most other resources I looked at; it deems sexuality during pregnancy a “vital area of education” for the childbirth educator. It’s comprehensive,eight pages or so, spends well over a full page on “teaching strategies” is very well-written and has good illustrations. Thanks again for pointing to it for us all.

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