Keywords

1 Introduction

The period after birth is challenging for couples, as childbirth itself may impact everyday life activities and the care for the newborn and might also affect their sexual life after childbirth. This chapter provides detail on physical and psychological trauma related to the process of labour and birth. It addresses various consequences that may impact their future relationship, such as perineal trauma, instrumental labour, the loss of the baby, loss of contact with the partner, or disappointment about the mode of birth. Alongside the theoretical notions, the chapter provides examples from clinical practice. This chapter aims to empower midwives in their important role in recognizing and helping the couple re-establish a healthy sexual relationship after birth.

2 Physical Birth Trauma

Several physiological changes in the woman’s body (in detail described in Chap. 8) influence postpartum sexuality. In brief, according to O’Malley et al. [1], almost 50% of women reported a lack of sexual interest in sexual activity, whereas 43% experienced a lack of vaginal lubrication, and 37.5% reported dyspareunia in the first 6 months after childbirth. In case of suffering birth trauma, these changes might be topped up with additional fears and potential pains that influence the frequency and quality of their postpartum sexual activity. Many women rarely seek help regarding sexuality since they tend to be more preoccupied with the newborn and self-care. Healthcare professionals (HCPs), including midwives, are the ones that have to initiate the conversation about sexuality. To provide efficient counselling, they must know about perineal and other injuries during childbirth.

2.1 Genital Tract Trauma

Up to 85% of women are estimated to sustain some form of genital tract trauma during childbirth [2]. That can be attributed to a certain degree of laceration of the cervix, vagina, perineum, or other parts of the genitalia. Perineal trauma may also result from episiotomy and an operative birth, such as vacuum or forceps labour, just as the abdominal wound after caesarean section (CS). Spontaneous perineal trauma may result in perineal tears, which can be mild, such as first- and second-degree tears, and extend into severe injury involving the anal sphincter, such as third- and fourth-degree tears. The last detailed statistics on perineal trauma during childbirth in European countries were given by the EuroPeristat Report from 2010 [3]. The incidence for first and second-degree tears was 4–58% and for third and fourth-degree tears was 0.1–5% [3].

The extent of the genital tract trauma influences postpartum recovery and impacts both the time of resuming vaginal intercourse and the possible development of dyspareunia. Even though the prevalence of dyspareunia in women is already relatively high, the incidence in the postpartum period is even higher, especially in association with perineal injuries. However, the condition often stays undiagnosed and is therefore undertreated. Women who sustained a second-degree tear or episiotomy experience lower arousal, orgasm, and sexual satisfaction and more dyspareunia at 12 weeks postpartum [4]. Globally, there are different practices regarding stitching or not stitching minor perineal lacerations. Leeman et al. [4] compared the results between no tear, tears with stitching and tears without stitching. At 12 weeks postpartum, they found no differences in urinary incontinence, anal incontinence, sexual activity, and sexual function [4]. Quite different is the situation in major injuries. In a Danish study, 50% of primiparous women with third or fourth-degree perineal tears reported dyspareunia even at 12 months postpartum. As expected, the best overall outcomes after 12 months were reported by those with no tears, tears of labia, or first-degree tears of the perineum [5].

Episiotomy is an iatrogenic perineal trauma. This ‘perineal cut’, the most frequent intervention during childbirth, is closely connected with perineal pain beyond the postpartum period and hinders women in resuming vaginal penetration. A Cochrane review comparing selective versus routine use of episiotomy found no benefits of routine use of this procedure, neither for the mother nor for the baby [6]. Therefore, according to the professional guidelines, the routine use of episiotomy is not recommended. Studies show that the intensity of postpartum pain is not affected by the mode of episiotomy (mediolateral or median). However, episiotomy causes more perineal pain than spontaneous second-degree perineal tears, even though the same anatomical structures are affected. After an episiotomy, women indeed reported more perineal pain, less sexual satisfaction, and a delayed sexual restart [7]. The anxiety of anticipated pain might also be the case of the delayed re-establishment of desired sexual encounters.

2.2 Trauma, Related to the Mode of Birth

Evidence suggests a link between the mode of birth and the impact on postpartum sexual function. Operative deliveries (by vacuum extraction, forceps, and CS) are associated with increased dyspareunia. Moreover, especially vacuum extraction and CS lead to increased rates of persisting dyspareunia up to 18 months postpartum.

The most common operative way of birth is CS, a major abdominal surgery and, as such, a vast physical trauma for women. The incidence of CS varies globally. Even though the WHO [8] recommends a CS rate of 10–15%, in some countries like Cyprus, Brazil, and Turkey, the CS rates exceed 50%. Besides the abdominal wound that is a significant source of pain, CS can also cause certain complications, including infection, haemorrhage, and incidental surgical injuries. Even though the perineum stays intact with a primary CS, a study by Blomquist et al. [9] reports that CS does not protect against postpartum dyspareunia. Women resume sexual intercourse quicker after the CS. However, a systematic review and meta-analysis by Fan et al. [10] reports no differences in postpartum sexual satisfaction between women after CS and women after vaginal birth.

A recent Danish study [11] looked at >43.000 women, on average 16 years after the first birth. CS was shown not to protect against long-term sexual problems. Vaginal birth (even after a previous CS) was associated with fewer long-term sexual problems. An important possible consequence of vaginal birth is trauma to the pudendal nerve. That is why some authors emphasized the potential protective role of CS as it will cause less pudendal nerve injury, less trauma to the pelvic floor, and no perineal damage [12]. This has been one of the controversial facts that led to the dilemma of whether women should be offered the choice of elective CS to avoid the development of pelvic floor dysfunction and possible postnatal sexual dysfunctions. However, both pregnancy and birth are significant factors for changes in the pelvic floor function; therefore, a routine caesarean section is not a solution to preserve the pelvic floor function.

Trauma related to childbirth may affect women as well psychologically, sometimes as a consequence of pain and occasionally independent of pain. On the one hand, the midwife plays a vital role in preventing soft tissue ruptures and unnecessary episiotomy. On the other hand, the midwife should provide the woman with information regarding pain management and wound care and address the topic of sexuality after birth, including the resumption of intercourse. It is important to discuss sexuality face to face with the woman or the couple and have that information also recorded in the discharge protocol. Community midwives should address this topic when caring for women in the postpartum phase at home.

3 Psychological Consequences of Physical Trauma

Childbirth may affect women psychologically, for instance, in the case of physical trauma, for example, the psychological damage of labour pain for which the woman was not prepared, totally unexpected pain or pain experienced as intolerable. That can also happen to the partner. While midwives have become familiar with people in pain, this is not the case for most partners, especially not when the loved person seems to be in severe pain.

Due to dyspareunia, the woman might avoid sexual intercourse. If she does not openly discuss that, the partner might not understand her avoidance, with the risk of extended avoiding any form of intimacy altogether.

Studies confirm that perineal trauma as an obstetric complication can result in psychological distress that can manifest in similar symptoms as post-traumatic stress disorder (PTSD) [13]. Besides psychological distress, it might affect partnership by diminishing the quality of sexual and marital interactions. Fear of pain when having intercourse and insecurities about body image is sometimes hard to discuss, especially if communication about sexuality was not well established before or during the pregnancy. In the case of major perineal tears, many women in the study by Skinner et al. [14] exhibited adverse coping behaviours. These authors have reported anxiety, avoidance, detachment from babies/partners, and numbing. There was distress that sexual relations were almost impossible and that involved unwelcome flashbacks of the birth and feelings of the stigma that their bodies were not adequate [14]. Crookall et al. [15] report less desire to be held or touched by her partner when the woman suffered more extensive lacerations during childbirth. Severe perineal trauma can result in many complications (such as urinary or faecal incontinence) that deeply affect a woman’s everyday life, impacting her self-esteem. In that case, the partnership (and, consequently, sexuality) come under pressure.

4 Psychological Trauma

As a consequence of childbirth, the woman, her partner, or both may experience several other birth-related psychological traumatic experiences. We should not underestimate that psychological trauma of the woman may arise from feelings of failure because the birth was not experienced as they expected and hoped for or did not take place within her ‘childbirth value system’ (like not giving birth vaginally). Women who see their birth as a traumatic experience might face long-lasting psychological effects [16].

Even when the midwife or any other HCP labels the birth as ‘normal’, the woman can undergo her labouring experience as traumatic. Indicated risk factors for experiencing birth as traumatic include: negative subjective birth experience, operative delivery, lack of support, and dissociation [17].

On the other hand, the woman’s partner may experience some form of psychological trauma as not being prepared for seeing some procedures or consequences of birth. Partners who experienced witnessing a traumatic birth of their woman reported this to negatively impact themselves and their relationship [18, 19]. Antenatal preparation for childbirth is important, just as good cooperation with the couple at the time of birth and in the postpartum period. When couples feel they are prepared for the challenges of labour and childbirth together, this can strengthen their bond through a period of major changes, thus creating an optimal relational context to start up intimacy and sexuality again postpartum.

Here, we successively address some traumatic experiences with their potential sexual consequences.

  1. (a)

    Loss of the baby. Sometimes this is preceded by an emotional rollercoaster of fear and nagging insecurity, but sometimes it is a sudden fact. The sexual consequences partly depend on how the couple’s sexuality has been developed. It also depends on the role sexuality has for each of them. For some couples, this experience becomes (also sexually) a strong bonding factor. However, other partners can gradually lose each other because of their differences in dealing with the loss and not understanding the other, including losing each other sexually.

  2. (b)

    Re-traumatizing of former abuse or sexual abuse. One may expect that most women will have sufficiently dealt with their negative past and can handle the not too complex situations, whereas others are (still) much more vulnerable. Even with optimal care, the situation can become traumatic, for instance, when suddenly a vacuum or forceps has to be applied, causing loss of control. Good aftercare can restore the disturbed balance in some women/couples, whereas psychological and sexual consequences can be long-lasting in others. Chapter 24 deals with those situations in more detail.

  3. (c)

    Loss of self. For instance, this can happen when the birth experience does not resemble what the woman had in her mind. When she has prepared herself for a natural first childbirth with candles and flowers but suddenly has to be rushed to the theatre for an emergency procedure, she can experience that as ‘failing’ in her role as ‘a natural mother’. Such a lost sense of self can easily reflect psychological issues with self-worth and consequently diminished sexual desire and damaged relationship with her partner.

  4. (d)

    Traumatizing of the partner. Whereas HCPs are used to blood and pain, we should realize that most partners are not! The husband who has seen the havoc of his wife’s third-degree tear can lose sexual desire for a long time.

  5. (e)

    Lost connection between the partners. Childbirth is a stressful experience that places high demands on dealing with each other, completely different from daily. The woman can become so introverted that her partner no longer seems to exist. Or she can curse her husband, screaming that she never, never wants to have sex again. Whereas the woman most probably has forgotten that after a week, some men can need months to get rid of those experiences. The man can himself cause the disconnection, for instance, when he arrives just before the birth in all his nervousness, smelling of alcohol. Such experiences can complicate the transition to healthy parenthood and renewed intimacy in the postpartum period.

  6. (f)

    Midwife (or other HCP)-related ‘damage’. In a retrospective search among >2.100 Dutch women who had experienced their birth as traumatic, many women indicated that their trauma could have been reduced or prevented with better communication and support by the caregivers. Other causes of ‘damage’ were mistreatment, verbal abuse, discrimination, and non-consented procedures [20]. Such breaches of mental integrity in women (who are nearly all vulnerable because in labour) easily can cause or intensify a negative sense of self. For some women, sexuality helps them reconnect to their inner selves. Still, this negative sense of self will impair pleasurable sexuality for many.

5 The Role of the Midwife

During childbirth, an essential role of the midwife is the prevention of soft tissue ruptures and unnecessary episiotomy. Preventive interventions should start in pregnancy (in the form of perineal massage after the thirty-fourth week) and during childbirth (warm compresses applied on the perineum, upright positions during birth, hands-on technique of perineal protection). When despite all efforts, an episiotomy is needed or lacerations occur, the wound should be adequately cared for, and the woman should receive unbiased and detailed information on the injury and its care.

Women often say that they did not get an explanation of what happened to their genitals during birth [14], and therefore, they might imagine their wounds as more severe than they actually were. Explanation from the midwife on what the woman can expect postpartum might help prevent or resolve unfounded fears and anxiety. The midwife should provide information on managing pain, care for the wound, and address the topic of first intercourse after the birth. With the woman’s consent, we should include the partner when discussing sexual aspects of recovery and dealing with sexual worries and questions. When we give such information on dyspareunia, we should do that without increasing the woman’s feelings of fear or anxiety. The couple should be encouraged to discuss sexual concerns and agree upon the timing of the first intercourse (both must feel ready). It should be outlined that it is entirely normal that many women (especially when breastfeeding) are not yet really in the mood for penetrative sex in the first period after childbirth. For many women, the focus is on the newborn baby. Therefore, it is crucial that both partners feel ready and choose the sexual activity that suits them both. Perhaps in the first days or weeks following childbirth, this should include cuddling without penetration, with the latter only added when the woman feels ready for it.

In postpartum sexuality problems, the midwife can determine which role to choose in caring for the couple’s postpartum sexual health (for instance, which level to pick up from the extended PLISSIT model, described in Chap. 3). However, in severe perineal trauma, the midwife must be alert and consider possible physical complications that might need a referral to other specialists. When the midwife cannot provide continued care after discharge from the maternity unit, the provided information on sexuality must be forwarded to the next HCP.

6 Conclusion

Midwives and other HCPs should understand possible changes in sexual life based on the mode of birth. They should give realistic information on the physical consequences of the interventions during birth and inform how to deal with pain. Besides, they should proactively address potential sexual effects and indicate possible ways to handle that. After birth, the midwife should offer proper consultation to all women who sustained childbirth-related trauma.

Therefore, health professionals who take care of women in the postpartum period must also address the topic of sexuality and intimacy in case of possible physical or psychological trauma. Sexuality issues should be dealt with and recorded in the discharge protocol for both the woman and her partner. Community midwives should address this topic when caring for women in postpartum home care. Since an open conversation between partners on sexuality and intimacy appears beneficial, the midwife should promote this from early pregnancy.