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' inChildbirth 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?' ⁵

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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