Midwives, health visitors and GPs are key in counselling and reassuring women about sexual problems after childbirth, as Dr Henrietta Hughes explains 

 ABSTRACT 
Following the birth of a child many physical, emotional and hormonal changes occur which can all have an impact. These include painful sex due to healing stitches or infection, low mood and depression and physiological changes due to breast-feeding or contraception. These can all affect the woman's sexual needs and impact on her relationship with her partner. Surveys of women postnatally suggest that there is an unmet need for discussing these issues and offering sensitive help and advice. Journal of Family Health Care 2008; 18(4): 123-125 

Key points
 
_ Health professionals should integrate questions about sex and sexuality into antenatal and postnatal checks
_ Exclude serious medical and psychological causes for loss of desire
_ Have a sympathetic and open approach

Background 
Libido is the medical term for sexual desire. After having a baby, loss of libido is a widespread but hidden problem for a woman. Hormonal changes and physical and emotional changes can all affect desire and lead to problems with the relationship with her partner1. Studies have identified a variety of sexual problems including vaginal dryness, painful penetration, pain during sexual intercourse, pain on orgasm, vaginal tightness, vaginal looseness, bleeding or irritation after sex, and loss of sexual desire2. Sex is less common towards the end of pregnancy and for most mothers there is only a slow return to prepregnancy levels in the first year after giving birth3. In one study, the median (average) time for restarting sex and contraception was six weeks2 but problems with sex were reported by nearly half of women over the next year. One in eight women wanted help with sexual problems but not all had discussed these with their doctor or midwife. Of first-time mothers, 83% reported experiencing sexual problems three months after delivery, but only 15% of women discussed this with a health professional3. Women reported that conversations with their health professional in the postnatal period focused mainly on contraception3. Women with pain in the perineum (the lower part of the vagina), depression or tiredness experienced more problems related to sex. Women who breast-fed their babies were significantly less interested in sex than those who bottle-fed2. The problems described above may be due to underlying medical and psychological reasons for decreased libido, and the following diagnoses need to be considered.
jfhc 18-4


Underlying medical disorders   
In the postnatal period, underlying medical conditions need to be borne in mind. Tiredness may be due to anaemia or an underactive thyroid. Vaginal thrush, bacterial vaginosis and low oestrogen levels due to breast-feeding or contraception can all lead to painful sex. Inflammation and infection of vaginal stitches, retained products of conception and infection of the lining of the uterus also need to be checked. Taking a careful history by listening to the patient is extremely important. Concerns about medical problems should be referred to the general practitioner (GP) or obstetrician for examination, vaginal swabs or blood tests and appropriate treatment.

Postnatal depression   
Postnatal depression is a major public health problem. It is a distressing disorder, more prolonged than the "blues" which occur in the first week after delivery but less severe than puerperal psychosis. Studies have shown that postnatal depression affects at least 10% of women and that many depressed mothers remain untreated4. These mothers may cope with their baby and with household tasks, but their enjoyment of life is seriously affected and it is possible that there are long-term effects on the family4. Recent NICE guidelines5 recommend that health care professionals should enquire, usually at 4-6 weeks and 3-4 months, whether in the past month the mother has been "bothered by having little interest or pleasure in doing things" or by "feeling down, depressed or hopeless". If the answer is yes, they should ask the mother whether this is something she feels she needs or would like help with. NICE also states that health professionals may consider using self-report measures such as the Edinburgh Postnatal Depression Score.
The Edinburgh Postnatal Depression Score (EPDS) was developed to assist health professionals in primary care to detect mothers suffering from postnatal depression6. It is a simple questionnaire with 10 questions which can be asked in outpatients, at home visits, or at the 6-8 week postnatal check. The scale can be completed in about five minutes and has a simple method of scoring. Women with an EPDS score greater than 10 should be referred to the GP or obstetrician for clinical assessment and suitable management. The following are risk markers for postnatal depression:
_ previous history of depression (postnatal or other)
_ unemployment
_ premature delivery
_ stopping breast-feeding in the first month for non-medical reasons7.

These risk markers can be used for first-line early screening by non-psychiatric health workers. Women with postnatal depression can be referred to the local Sure Start emotional support team and the voluntary organisation Meet a Mum Association (MAMA) (see Resources), a charity which aims to provide friendship and support to all mothers and mothers-to-be, especially those feeling lonely or isolated after the birth of a baby.

Breast-feeding and libido   
Breast-feeding is important in this context because of the hormonal changes it produces. Breast-feeding mothers may experience painful sex due to low oestrogen levels8. A study has shown a significant decrease in tiredness, an improvement in mood, and an increase in sexual activity, sexual feelings and frequency of sex within four weeks of stopping breast-feeding9. This is not to suggest that breast-feeding should be discontinued, but it may be helpful to reassure women that it is normal to have less desire while breast-feeding, and to offer advice such as lubrication to reduce painful intercourse. Further advice and support for breast-feeding can be obtained from one of the breast-feeding organisations such as La Leche League (see Resources).

Feelings 
Women's feelings about themselves and their new role after childbirth are very important. A study to investigate women's thoughts about sexual life after childbirth identified four themes1:
_ The women did not feel comfortable with the physical changes that had taken place and their body image, making them less keen to have sex
_ Childbirth meant less sleep and less free time; consequently, instead of having sex, women wanted to sleep or have time for themselves, which led to a changed sex pattern
_ A difference between their sexual desire and that of their partner was a problem but most of the women expressed confidence that their sexual desire would return shortly. Women found that reassurance and confirmation that they were physically all right and back to normal was essential1.

Painful sex   
The method of delivery is a significant factor in dyspareunia (painful sex) after childbirth. A cohort study found that women who had an intact perineum reported the best outcomes overall, whereas perineal trauma and the use of obstetric instruments made it more likely that sex would be painful postpartum10. This indicates that it is important to minimise the extent of perineal damage during childbirth10. In the six months after delivery, women in the group who had a mediolateral episiotomy had more pain, less arousal and lubrication, fewer orgasms and less satisfaction when compared to scores before pregnancy and compared with women who had had a Caesarean section. Many hospitals have policies regarding mediolateral episiotomy and it has been suggested that its use should be restricted11. The type of stitches used can also affect pain in the perineum. Continuous stitches, compared to interrupted methods, lead to less short-term pain, particularly if used for all layers (vagina, perineal muscles and skin)12. Women who have tears in the anal sphincter muscle at vaginal delivery also report less frequent sex in the first six months after birth13.

Discussion   
Advice on restarting postpartum sex is mainly to be found in agony aunt pages rather than in the medical literature14,15,16. Perhaps this is because conversations with health professionals focus mainly on clinical issues such as contraception17.
This focus may not be the only way of meeting women's needs after childbirth. When a woman does not return to full sexual function, the explanations available to her tend to emphasise natural/ biological, physical and psychological factors16. However, these explanations may fall short of describing the experiences of many women. Before embarking on clinical explanations, professionals need to allow opportunities for women to raise the issues and concerns that are significant to them, so that women may explore changes in their experience of their own sexuality.
For example, it may be helpful to discuss alternatives for full penetration if there is a mismatch in the sexual desire of both partners16. Women should be advised about lubrication, counselled about parenting and relationship issues, and provided with a confidential place for discussion, without embarrassment on the part of the health professional.
To help women to anticipate changes in their lives after childbirth more fully, midwives need to facilitate discussion of sexuality - not just sexual activity - during antenatal preparation and postnatally17. It can be helpful to include partners in such preparation. GPs, health visitors and their teams and other health professionals should also be alert to these issues and be able to educate and prepare patients antenatally. We should be trained to identify problems, and be competent to deal with them openly and sympathetically2. New mothers are concerned with their body image and the ability to adapt to parenting. They need sensitive, professional counselling and reassurance about their body, as well as about sexual life after childbirth.
This should not be confined to the postnatal check but should also be available in the subsequent months. For example, health visitors could sensitively raise these issues, as well as enquiring about urinary and bowel continence, when mothers come for the baby's developmental check at around eight months. This level of professional counselling is presently not widely available to new mothers. Midwives, health visitors, GPs and obstetricians should be the key persons to provide this service.
 

Uploaded May 2008. Written by Henrietta Hughes MA MBBS MRCGP DRCOG DFFP General Practitioner London  

References 
1. Olsson A, Lundqvist M, Faxelid E, Nissen E. Women's thoughts about sexual life after childbirth: focus group discussions with women after childbirth. Scandinavian Journal of Caring Sciences 2005; 19(4): 381-387 2. Glazener CM. Sexual function after childbirth: women's experiences, persistent morbidity and lack of professional recognition. British Journal of Obstetrics and Gynaecology 1997; 104(3): 330-335
3. Barrett G, Pendry E, Peacock J, Victor C, Thakar R, Manyonda I. Women's sexual health after childbirth. BJOG: An International Journal of Obstetrics and Gynaecology 2000; 107(2): 186-195
4. Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression. British Journal of Psychiatry 1993; 163: 27-31
5. National Institute of Clinical Excellence (NICE). Antenatal and Postnatal Mental Health. London: NICE, 2007. www.nice.org.uk/guidance/CG45
6. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 1987; 150: 782-786
7. Jardri R, Pelta J, Maron M et al. Predictive validation study of the Edinburgh Postnatal Depression Scale in the first week after delivery and risk analysis for postnatal depression. Journal of Affective Disorders 2006; 93(1-3): 169-176
8. Alder EM. Sexual behaviour in pregnancy, after childbirth and during breast-feeding. Baillière's Clinical Obstetrics and Gynaecology 1989; 3(4): 805-821
9. Forster C, Abraham S, Taylor A, Llewellyn-Jones D. Psychological and sexual changes after the cessation of breast-feeding. Obstetrics and Gynecology 1994; 84(5): 872-876
10. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. American Journal of Obstetrics and Gynecology 2001; 184(5): 881-888
11. Baksu B, Davas I, Agar E, Akyol A, Varolan A. The effect of mode of delivery on postpartum sexual functioning in primiparous women. International Urogynecology Journal and Pelvic Floor Dysfunction 2007; 18(4): 401-406
12. Kettle C, Hills RK, Ismail KM. Continuous versus interrupted sutures for repair of episiotomy or second degree tears. Cochrane Database of Systematic Reviews 2007; 4: CD000947. Update of: Cochrane Database of Systematic Reviews 2000; 2: CD000947
13. Brubaker L, Handa VL, Bradley CS et al; Pelvic Floor Disorders Network. Sexual function 6 months after first delivery. Obstetrics and Gynecology 2008; 111(5): 1040-1044
14. www.cookiemag.com/homefront/mrsyoung/2007/10/mrsyoung postpartum (accessed 10 June 2008)
15. www.netdoctor.co.uk/womenshealth/features/sexualdesire.htm (accessed 10 June 2008) 16. www.netdoctor.co.uk/sex_relationships/facts/sexdelivery.htm (accessed 10 June 2008)
17. Curtis P, Dunn K. Sex and sexuality. Modern Midwife 1996; 6(5): 26-29

RESOURCES

Sure Start Website: www.surestart.gov.uk

The Meet a Mum Association (MAMA) Registered UK charity aiming to provide friendship and support to all mothers and mothers-to-be, especially those feeling lonely or isolated after the birth of a baby or moving to a new area. Has local branches and can put individual mothers in touch with each other. Helpline: 0845 120 3746 (7pm-10pm, weekdays only) Website: www.mama.co.uk
Some organisations providing breast-feeding supportAssociation of Breastfeeding Mothers Voluntary organisation offering breast-feeding women mother-to-mother support, counselling and information. Helpline: 0870 401 7711 Website: www.abm.org.uk
Breastfeeding Network Voluntary organisation offering free, confidential information and one-to-one breast-feeding support by trained volunteers Supporter line: 0844 412 4664 Services in Bengali/Sylheti: tel 0844 856 4003 Website: www.breastfeedingnetwork.org.uk
La Leche League GB Voluntary organisation providing friendly mother-to-mother breast-feeding support from pregnancy through to weaning. Has local groups. Helpline: 0845 120 2918 Website: www.laleche.org.uk
National Childbirth Trust Charity providing education and information on breastfeeding and parenting. Has local groups and trained breastfeeding counsellors. Breastfeeding line: 0870 444 8708 Website: www.nct.org.uk
NHS Breastfeeding Line New Government-funded national UK helpline providing a telephone helpline service from 9.30am - 9.30pm every day.