What About Sex After Baby?

This week's blog is guest co-written with Kala Plasterer.  Kala will share a bit about herself below, but I’m delighted to bring in a mother, OT, and someone passionate about sex after baby to write about this topic.  Kala and I have been working together for a while as she is a virtual assistant to The Institute.  It was a no brainer to have her write about sex after baby!   

When it comes to addressing sex and intimacy, the impact of breastfeeding and pelvic floor muscles (PFM) may not be the first thing that comes to your mind... but, they will hopefully be something you consider after reading this!

A little bit about me.. I'm Kala. An occupational therapist, first-time mom, and virtual assistant for Kathryn! My personal journey with breastfeeding and motherhood fueled a fire within me and has motivated me to pursue a niche path as an OT and become a certified lactation consultant (CLC). As I’m sure is the case with many of us, we are often driven by personal experience. My goal is to make the journey through postpartum and breastfeeding one that is less stressful for mothers.

You may work with breastfeeding parents in an acute, outpatient or virtual setting where the primary reason for referral isn't lactation, PFM difficulties, or to discuss sexuality and intimacy but, understanding how these areas can impact sex, will help provide better holistic care.

Unfortunately, as many of us know, addressing sex is still seen as taboo in many settings. And I'm here to tell you the single postpartum visit with a primary care provider at 6 or 12 weeks postpartum is no different. So, for OTs to truly be holistic practitioners, it’s important that we understand the basics to provide patient education and make referrals when needed!

Hormones

I recently watched a great IGTV video by TheBalancedBoob, Breastfeeding and Sex, that explains so much about hormones during breastfeeding. When a parent first becomes pregnant their estrogen level goes from somewhere between 50-300 to practically 3000! But, once they have their baby, their estrogen level drops big time, all the way down to 0 (that's menopausal, just fyi!).

Why does this matter??

Estrogen is the hormone responsible for keeping the skin of the vulva, vagina and perineum lubricated and robust. So when it plummets after giving birth, the skin of those areas often becomes dry and tender which can make sex understandably painful. Not to mention any tears, lacerations or incisions that occurred during delivery and are still healing. Although estrogen levels tend to gradually increase over the first 6 months postpartum, breastfeeding can lengthen the amount of time it takes for the prior “normal” level of estrogen to be reached... further drawing out the potential symptoms of vaginal dryness, tenderness and pain.  Why does the estrogen plummet?  To reduce the likelihood of another pregnancy during the time the parent is using all of their resources and energy to care for and nourish the newborn.

But estrogen is just one piece of the puzzle…

Pelvic Floor Muscles

It’s important to also understand the impact that pregnancy can have on pelvic floor muscles and having Sex After Baby. This 3 layer system of muscles has many roles…providing stability, holding the bladder and uterus in place, and carrying the weight of the baby during pregnancy.. to name a few. No matter how the baby is delivered, the pelvic floor muscles have been impacted. And just like any other muscle in your body these muscles can be weak or too strong. Weakness can lead to leaking urine when you cough or sneeze, vaginal prolapse, and passing wind when bending over or lifting. Tightness can lead to pain during sex, difficulty urinating, constipation, and pain that intensifies with movement. 

So what’s our role when addressing sex and intimacy??

1. If you’re working with a client who you know has young children you can ask if they’re still breastfeeding (remember, it’s important to not assume that because the child is a certain age that they aren’t still breastfeeding).
2. Provide education on how estrogen levels impact the skin of the vulva, vagina, and perineum and that breastfeeding can delay it returning to a "normal" level.
3. Share good news! If they are dealing with vaginal dryness and pain due to the low estrogen levels that accompany breastfeeding they can ask their OB/GYN for a prescription topical estrogen cream. This simple intervention can have a profound effect and help with symptom management. AND you can assure the client it's completely safe to use while breastfeeding and will NOT impact their supply.
4. Remind parents that because of the hormonal changes the body experiences during postpartum and breastfeeding, on top of having a baby who needs to feed often, wakes up often, and leaves parents feeling fatigued it’s very understandable if both parents libido also take a nosedive for a while! Some people will put a lot of pressure on themselves to “bounce back” by their 6 week postpartum appointment when they’re typically given the A-okay to resume sexual activity.. if they had a non-traumatic vaginal delivery (it's typically 12 weeks for a C-section).
5. The OT can work with clients postpartum who are having difficulty with having the energy and desire for sexual activity.  OTs can do activity analysis, suggest energy conservation, and help the parents infuse their day with just a little bit of activities that build desire despite the compressed schedules.  And lastly, giving fatigued parents a heads up about sex can be very helpful to getting that enthusiastic yes, so encouraging couples to schedule their other priorities around sex can also be a great suggestion.  This gives everyone time to start transitioning their minds/bodies from the very non-erotic task of parenting and mothering to a much more erotic space for expressing themselves sexually.  

But what if she’s not ready?? What if they’re not feeling quite themselves yet?? Or what if it still hurts to even perform toilet hygiene??

Dr. Sam DuFlo gives great recommendations in Sex After Baby about how to help our clients ease back into having sex.

• Recommend using a hand mirror to become familiar and comfortable with the vulva and vagina again. Things may or may not look the same.
• Try self-pleasure. Recognize that orgasm could change after delivery. What was once a climactic experience might not feel the same. If they share that things do feel different, or that they’re having pain, leaking urine, or have any concerns at all this is a great opportunity to make a referral to a Pelvic Floor Therapist! 
• Recommend considering different sex positions, incorporating lube, or starting with non-penetrative sex.
• And lastly, remind your client that they’re not alone! Hormone levels should begin to increase over time, even while still breastfeeding, but the rate at which that happens is different for everyone.