When is postpartum sex too soon?

I was watching a video on TikTok from one of my favorite creators and the content referenced a woman’s partner upset that she wanted to wait to have sex after childbirth. I chose to contribute to her conversation stating “Medically it’s recommended to wait a few months, 5-8 months to properly heal” (I meant ‘maybe she should wait a few months 5 to 6 months to properly heal’, but I was not going to edit on the go; plus deleting comments are always interrupted differently with each person when I was willing to converse without malicious intent ); and a woman saw my comment and stated “cite your resources”. I admit their comment without punctuation reads boorishly; although it could have been curiosity. I engaged with them and stated they should google more and more into other pregnancies. At some point during the engagement they stated they had 6 children and was fine. I was happy her pregnancies were good because I know not everyone gets to have them smooth. I had explained in limited characters about having sex too soon for a woman can become problematic and to completely heal 100%. They discussed 4-6 weeks or 8 weeks if they had a C-section. I began to refer to postpartum depression, postpartum psychosis, postpartum dyspareunia, postpartum hemorrhage & uterine infections; and even a study discussing painful sex after childbirth. It sounded like they were comparing their childbirth experiences as the only way to experience when I know women who were shredded during their pregnancy while another bounced up the next day to make breakfast; like it was nothing. I also explained everyone’s body is different. I finally ended it with an analogy about breaking a bone, sure there is a specific frame of when someone should heal from it but if you’re still feeling pain from the break that means the body hasn’t full healed. I also referenced an article about a study.

After this back and forth, I was intrigued why the woman was seemed upset about my commentary to the Tiktoker; so here we are. I figured I would put it all together because not everything can be summed up in a 100 character message.

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What’s going on during pregnancies? During pregnancy the body produces a hormone called relaxin released from the corpus luteum in the ovaries (and placenta); this hormone allows the ligaments in the joint between the left and right pelvic bones to become more relaxed to prepare for birth. As the pelvic bones begin to loosen up the pubic symphysis which are cartilaginous joints between the left and right superior rami of the pubis of the hip bone. Cartilaginous joints are a type of joint where bones are joined by cartilage tissue either hyaline (usually found with synovial joints like your nose) or to fibrocartilage ( which are super tough tissue predominantly in the intervertebral disks & ligaments and tendons insertions). The cartilaginous joint allows for that flexibility to push out the baby so the pubic symphysis separates temporarily; usually. Sometimes it becomes too lose after birth. Heck you can develop osteoarthritis in the pubis symphysis. However, it will take a few months for the body to stop producing relaxin completely while the body begins to tighten back up; this will vary between each pregnancy. It will gradually go and change like the other hormones in your body.

After a baby is born the body removes the blood and tissue that was inside the uterus; this lochia or vaginal discharge is common. The blood begins bright red and eventually lightens up. A woman’s estrogen hormones tank. The perineum (the area between the vagina and anus) will be soar from stretching during birth, or in some pregnancies the perineal tear; which affects “about 80% of women during childbirth, with primiparous women being affected more frequently than multiparous women” (Jansson et al., 2020) Multiparous women is used for women who have given birth more than once; which would make sense because the primiparous (first time pregnancy) woman would have already “tore it open”. Every single pregnancy is different between women and can even be the same woman but different babies.

What could be a risk for the woman physically?

If sex happens too soon right after childbirth she can risk postpartum hemorrhaging which can be caused by a tear in the cervix, tear in a blood vessel in the uterus, a hematoma in the vulva, blood clotting disorder or placenta problems. I don’t think I need to explain why bleeding out is not a good thing.

“Obstetric anal sphincter injuries (OASI) are the largest obstetric risk factor for developing anal incontinence in women, so these tears merit particular attention. However, although less attention has been paid, second-degree tears alone may impair sexual function and increase the risk of future pelvic organ prolapse , and high vaginal tears have been associated with increased risk for levator muscle avulsion. But the incidence and risk factors of these tears have been poorly investigated.” (Jansson et al., 2020) For serious tears that create the problem of an OASI for the patient are concerning because the sphincter is the ring muscle that plays an important role in controlling bowel movements; the muscle is weakened that means the person will begin to have trouble controlling their bowel movements (inconstinence) or loss of stool.

“The external female genitalia are composed of the mons pubis, labia majora, labia minora, clitoris, vaginal vestibule, and the perineal body, all of which can be damaged during childbirth. The perineal body is the most common site of laceration; it is a mass of dense connective tissue that includes superficial and deep muscles of the perineal membrane, including the transverse perineal muscles and attachments of the bulbocavernosus muscles.” (The American College of Obstetricians and Gynecologists, 2016). As a side note during the baby’s grand entrance to the world the baby’s head can fracture the woman’s coccyx/tailbone, and although considered vestigial it’s still the best friend needed…when sitting on your tailbone.

The mons pubis is fatty tissue in front of the pubic bone and usually covered in pubic hair. The mons pubis acts like a cushion during sex and contains sebaceous glands that secrete pheromones to induce sexual attraction. It’s like a purring pair of lips whispering to your desirable; this can be damaged during childbirth which would contribute to painful sex. The labia majora are the larger lips everyone is familiar with and engorges with blood during sexual arousal. The labia majora engorges with blood and appears edematous during sexual arousal; enough that it can appear “swollen” or filled with fluid (edematous). The clitoris, though it sounds foreign to some…its the female sex organ that functions like as a sensory organ; meaning they have specialized sensory neurons…to help us perceive the environment or rather the pleasure of it. The part of the clitoris that is visible is the glans clitoris which is filled with nerves and blood vessels; hence why it’s the most important part to play with but I digress.

How does this affect sex? 6 weeks I should be good right? Well, maybe and not necessarily. Let’s say the pelvis becomes too relaxed and the patient experiences pain in the pelvic girdle; indicating symphysis pubis dysfunction (SPD). The prominent symptom of the pain is described as a shooting, burning sensation that is felt over the pubic bone, between the vagina and anus, on one or both side of the lower back and radiating into the thighs. SPD will make it difficult to walk around, lifting objects or move the legs apart…like for sex.

There’s also oseteitis pubis (itis meaning inflammation) which would mean the patient can experience inflammation of the symphysis joint of the pelvis, which sits right under the beautiful mons pubis. This can occur with athletes but also from pregnancy.

Issues with the labia majora could be the sign of a yeast infection, or an imbalance of bacteria in the vagina (called bacterial vaginosis), an allergy or an infection. It could also just be due to friction from having sex; including if the body isn’t ready.

If you have a fracture, healing can take between 8 to 12 weeks. If your tailbone injury is a bruise, healing takes about 4 weeks. Looking at a fracture this would mean healing between 2 months to 3 months of healing; for this specifically alone.

Clitoral tearing, not common but it can happen during child birth; takes two weeks for that to heal. About half of all women who give birth vaginally will experience permanent changes to their body (the pelvic floor) from grand entrance of the baby. When the pelvic muscles are damaged or weakened the organs inside the pelvis can actually drop down towards the vagina which would only cause bladder and bowel issues. The pelvic floor holds those lovely items in their place.

If the woman has a c-section it’ll be due to complications and the doctor will be make a 10-20 cm incision just below the bikini line. C-sections typically take about 45 minutes including (as little as) 15-20 minutes to deliver the baby; the rest is stitching up the uterus and stomach. Generally organs are not taken out or anything like that but the bladder may be moved to get to the fetus out.

Now dyspareunia is painful sex and 50% of women report painful sex after giving birth. This can be due to vaginal dryness from the changes in the body. There are a multitude of things. In 2005 an article stated “Several research studies1,4,5,7-11,12 have reported that 62-88% of women resume intercourse by 8–12 weeks postpartum. However, 17–23% continue to experience superficial dyspareunia at three months after delivery and 10–14% at 12 months. Barrett et al.1 reported a higher prevalence rate: 62% of women in their study experienced dyspareunia at some time during the first three months postpartum and 31% still complained of dyspareunia at six months. However, 12% of the study participants had experienced dyspareunia in the 12 months prior to conception.” (Kettle et al., 2005)

In recently reports in 2018 “Nearly half of the women (46.3%) reported a lack of interest in sexual activity, 43% experienced a lack of vaginal lubrication and 37.5% of included women had dyspareunia 6 months after birth. On univariate analysis, vacuum-assisted birth, 2nd degree perineal tears, 3rd degree perineal tears and episiotomy were all associated with dyspareunia 6 months postpartum, but, of these only 3rd degree tears, in association with breastfeeding and pre-existing dyspareunia, remained significant on multivariable analysis. Breastfeeding, in combination, with other significant factors, was associated with dyspareunia, a lack of vaginal lubrication and a loss of interest in sexual activity 6 months postpartum, and, dissatisfaction with body image emerged as a significant factor associated with lack of interest in sexual activity at 12 months postpartum. Pre-pregnancy dyspareunia and breastfeeding emerged as common factors associated with all three outcomes of dyspareunia, a lack of vaginal lubrication and a loss of interest in sexual activity at 6 months postpartum.” (Malley et al., 2018)

“Postpartum dyspareunia (PD) is a recognized phenomenon: it is estimated that 50-60% of women have dyspareunia 6 to 7 weeks following delivery, and 33% and 17% will still report pain during intercourse three and six months after delivery, respectively.” (Meir Medical Center, 2015). If they are feeling pain then they may not be fully healed to do so.

Am I saying you can’t have sex until 6 months? No I’m not clinically stating, but if a partner is pushing it or upset that she needs more time; is a lot of pressure on the woman physically, emotionally and mentally. There’s pressure on the relationship. The new baby having needs and not sleeping then sleeping. There’s a lot that goes into it. Child birth is not going to be the same for everyone. I had one friend whose child was making quite the entrance to the world leaving her feeling shredded (which took her more than 8 weeks to heal, her second birth seemed smoother but probably because her first made way lol) and my other friend came home and woke up to make breakfast in the morning. It seems like the situation is treated like a whatever thing when each body handles things differently. Hell even men have been reported to experience postpartum depression; but it did not sound like it based on the limited context of the content.

Medicine and science is a beautiful thing. I think the human body is capable of some incredible feats and we learn new things in science everyday (especially if you nerd out in it); things we know now are all improvements of things we laugh at today. There is a lot at stake with pregnancy. Maybe this guy is impatient. Maybe he’s not concerned about her healing. Maybe he’s bothering her 1 week in without giving her body time to heal when stitches alone will generally take 2 weeks; unless it is a more complex surgical stitching required. This does not include additional medical conditions or medications that can alter the time frame. Maybe it has been 6 weeks and it is something else, or perhaps she’s part of that 33% or 17% suffering from painful sex and it’s been 4 or 5 months; maybe she tried it and it didn’t work. Maybe the patient is suffering from spd and opening her legs is incredibly painful and she needs more time to heal.

And perhaps the woman was confused about what I said; so here it is 🤷‍♀️

References

The American College of Obstetricians and Gynecologists, . (2016). Practice bulletin no. 165: Prevention and management of obstetric lacerations at Vaginal Delivery. Obstetrics and gynecology. Retrieved May 20, 2022, from https://pubmed.ncbi.nlm.nih.gov/27333357/

Bani, D. (1997). Relaxin: A pleiotropic hormone. General pharmacology. Retrieved May 20, 2022, from https://pubmed.ncbi.nlm.nih.gov/9112071/

Cleveland clinic, . (n.d.). C-section (cesarean birth): Procedure & risks. Cleveland Clinic. Retrieved May 20, 2022, from https://my.clevelandclinic.org/health/treatments/7246-cesarean-birth-c-section

Cleveland Clinic, . (n.d.). Symphysis pubis dysfunction: Causes, symptoms & treatment. Cleveland Clinic. Retrieved May 20, 2022, from https://my.clevelandclinic.org/health/diseases/22122-symphysis-pubis-dysfunction

Gommesen, D. (2019, August 23). Medline ® Abstract for Reference 44 of 'Obstetric anal sphincter injury (OASIS)'. UpToDate. Retrieved May 20, 2022, from https://www.uptodate.com/contents/obstetric-anal-sphincter-injury-oasis/abstract/44

https://www.pregnancybirthbaby.org.au, . (n.d.). Birth injury (to the mother). Pregnancy Birth and Baby. Retrieved May 20, 2022, from https://www.pregnancybirthbaby.org.au/birth-injury-to-the-mother

Jansson, M. H., Franzén, K., Hiyoshi, A., Tegerstedt, G., Dahlgren, H., & Nilsson, K. (2020, December 2). Risk factors for perineal and vaginal tears in primiparous women – the prospective POPRACT-cohort study - BMC pregnancy and childbirth. BioMed Central. Retrieved May 20, 2022, from https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-03447-0

Kersigo, J., D'Angelo, A., Gray, B. D., Soukup, G. A., & Fritzsch, B. (2011, April). The role of sensory organs and the forebrain for the development of the craniofacial shape as revealed by Foxg1-Cre-mediated microrna loss. Genesis (New York, N.Y. : 2000). Retrieved May 20, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3079063/

Kettle, C., Ismail, K., &; O’Mahony, F. (2005). Management of chronic pelvic pain: Evidence from ... - elearning. Retrieved May 21, 2022, from https://elearning.rcog.org.uk/sites/default/files/Pelvic%20pain/Cheong_TOG_2006.pdf

Meir Medical Center, . (2015, April 8). Postpartum dyspareunia resulting from vaginal atrophy - full text view. Full Text View - ClinicalTrials.gov. Retrieved May 20, 2022, from https://clinicaltrials.gov/ct2/show/NCT01319968

Nguyen, J. D., &; Duong, H. (2021, July 31). Anatomy, abdomen and pelvis, female external genitalia - NCBI bookshelf. National Library of Medicine. Retrieved May 21, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK547703/

O’Malley, D., Higgins, A., Begley, C., Daly, D., &; Smith, V. (2018, May 31). Prevalence of and risk factors associated with sexual health issues in primiparous women at 6 and 12& ;months postpartum; a longitudinal prospective cohort study (The mammi study) - BMC pregnancy and childbirth. BioMed Central. Retrieved May 20, 2022, from https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1838-6

Society for endocrinology. (n.d.). Home. You and Your Hormones. Retrieved May 20, 2022, from https://www.yourhormones.info/hormones/relaxin/

Staff, F. E., &; Rice, A. (2020, August 28). Recovering from delivery - postpartum recovery. familydoctor.org. Retrieved May 20, 2022, from https://familydoctor.org/recovering-from-delivery/