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CHAPTER 5

Pregnancy and Childbirth

IF A HUMAN COMES OUT OF YOUR BODY there will be physical changes. While I believe that most women understand this intuitively, the magnitude or the reality (or perhaps both) are often a surprise, especially when almost no one talks about the changes they experience after pregnancy. Knowing what to expect after you are finished expecting is very helpful, both so you have a realistic baseline, but also so you know when there is a medical concern and should ask for help.

We don’t talk openly about the postpartum period for a lot of reasons. Women are shamed when their body doesn’t conform to an impossible ideal set by the patriarchy. Until relatively recently, both society and the medical profession have focused almost exclusively on the baby after delivery. Women also used to stay in the hospital much longer after delivery than they do today and/or they had a home visit from a knowledgeable nurse, so there was someone who they could easily ask about pain, bleeding, or bowel movements without having to figure out how to take a one-week-old to a doctor’s appointment.

Pregnancy Changes

Changes to the cervix, vagina, and vulva can start as soon as 4–5 weeks into the pregnancy. Increased blood flow and hormonal changes cause the vagina and vulva to engorge with blood. Consequently, the vaginal mucosa (skin) may look blue due to a change called Chadwick’s sign. The skin and muscles soften. The cells on the inside of the cervix proliferate and expand onto the portion of the cervix in the vagina. This is called an ectropion. It can result in more vaginal discharge, and these cells may bleed when touched—for example, after penetrative sex or a Pap smear. Never assume this is the source of any vaginal bleeding, as there are also serious medical conditions that can cause bleeding during pregnancy.

Yeast infections are more common during pregnancy, although the exact mechanisms are unknown. It may be due to the very high levels of estrogen and/or progesterone, the immune suppression during pregnancy, or other factors.

In the third trimester, around thirty-five weeks, a vaginal test for a bacteria called group B streptococci (strep) is performed. The bacteria is normally found in the vagina and/or rectum of 10–30 percent of women. This requires treatment with intravenous antibiotics during labor to reduce the risk of serious infection for the newborn. It should not be treated with home remedies, such as garlic, that you might find suggested online. A pregnant woman with group B strep who does not receive antibiotics has a 1 in 200 chance that her baby will develop the infection, but if she is treated that risk drops to 1 in 4,000.

Sex during pregnancy

It is not uncommon for women to report a decrease in desire in the first and third trimesters. Whether this is due to worries about a complication in the pregnancy caused by sexual activity, a changing body image, discomfort with sex, or back pain is not known. Some women do report an increase in desire.

Some women worry that heterosexual sex during pregnancy could trigger a miscarriage or preterm labor and delivery. Fortunately, we know that women with a low-risk pregnancy who have no symptoms of a vaginal or cervical infection are at no higher risk of having a premature delivery if they are sexually active.

Contrary to urban myth, sexual intercourse close to the due date with a male partner does not appear to trigger labor. Many people talk about exposure to prostaglandins, substances known to trigger labor, from ejaculate, but it is not supported by science. Most studies show that heterosexual sex has no effect on triggering labor or on reducing the risk of cesarean section. The idea that a penis is mighty enough to bring on labor is, to be honest, a bit eye-rolling. Nipple stimulation when the cervix is ripe can trigger labor for some women, but you don’t need a penis for that.

It’s recommended to avoid sexual activity for women in some higher-risk situations, such as ruptured membranes, placenta previa (where the placenta implants over or next to the cervix), and those who have a high risk of premature delivery (for example, twins or a previous preterm delivery).

Many people have heard about reports of fatal air embolism in pregnancy from both receptive oral sex (cunnilingus) and penile-vaginal sex. An air embolism is a stroke or heart attack due to a large air bubble entering an artery or vein and traveling to the brain, heart, or lungs. The placenta has a direct connection with the maternal bloodstream, and so with enough pressure it is possible for air to travel up through the vagina into the uterus and enter the bloodstream. Air can be introduced by oral sex or with penile thrusting.

Air embolism is described in fewer than one in a million pregnancies, so it is hard to give science-based recommendations. It is best to avoid blowing air into the vagina during oral sex, and some have suggested that the risk of air embolism during penile penetration may be greatest in positions where the uterus is above the level of the heart, but that recommendation is not based on any studies.

Ancient Obstetrical Practices That Should Be Forgotten!

Before I trained as an OB/GYN, shaving, enemas, and cleaning the vulva and vagina with antiseptic were common, but now we know these practices are outdated. This isn’t The Pregnancy Bible, so I can’t go into every question you should ask your provider, but if the person delivering your baby supports a practice that is more than twenty-five years out of date, such as shaving or enemas, I might wonder about the currency of other aspects of their medical care. It’s best not to shave yourself before labor either, as this causes microtrauma and may increase your risk of infection.

During delivery, you may have a bowel movement. It is completely normal. Your OB/GYN or midwife should not even notice, that is how routine it is for us. We just wipe the stool away. If it were harmful for the baby, we would not have evolved so the baby’s head emerges next to the anus!

Perineal Trauma

Trauma is part of vaginal delivery (it’s obviously part of a C-section as well). The vulvar and vaginal tissues have evolved to stretch, tear, and recover—the increased blood flow, how quickly the cells of the vagina are shed and replaced, and the extra folds of vaginal mucosa are very helpful.

Both tearing and an episiotomy (a surgical cut) are collectively called perineal trauma. Many women ask how many stitches they needed, but that is not a reflection of the severity of the injury. A single stitch can be run like a hem and close a large tear. Multiple tiny stitches may be needed to repair a much smaller laceration to achieve the best cosmetic result. What you should ask is the extent of the injury, which is described by OB/GYNs in degrees based on muscle injury:

• First degree does not involve muscle. It is limited to the vaginal mucosa, the vestibule (vaginal opening), and/or the skin of the vulva.

• Second degree extends into muscles and can vary significantly in size, meaning a small partial tear of the muscles beneath the vestibule or all the way through the muscles of the perineal body, stopping just before the anal sphincter.

• Third degree involves all the muscles of the perineal body and the rectal sphincter (it is further subdivided by how much sphincter is involved).

• Fourth degree extends all the way through the anal sphincter into the rectum; fortunately this occurs in only 0.25–2.5 percent of births.

First- and second-degree lacerations should be repaired if they are bleeding or if not repairing them would lead to an unsatisfactory cosmetic result. Absorbable skin sutures or surgical glue can both be used. However, third- and fourth-degree lacerations should be repaired surgically (sutured)—if not, there is a higher risk of fecal incontinence. A first-or second-degree laceration has no increased risk of urinary or anal incontinence, but the risk is increased with third- and fourth-degree tears.

Routine episiotomies are not recommended by the American College of Obstetricians and Gynecologists (ACOG). The most recent data tells us that 12 percent of vaginal births in the United States involve an episiotomy, down from 33 percent in 2000. The number of episiotomies should keep going down, given ACOG’s policy advising against them. Episiotomy is associated with a larger injury and an increased risk of incontinence. In general, an episiotomy is only indicated in an urgent or emergent situation. I don’t know any OB/GYN who practices routine episiotomy, although I have no doubt that a few still do. This is definitely something to inquire about at one of your prenatal visits.

The risk of tearing during a vaginal delivery ranges from 44 to 79 percent—any provider who tells you they can guarantee no tears is not being honest. Most factors that lead to tearing are not within your control, including the size of your baby, whether or not this is your first delivery, and genetics. An epidural has not been shown to affect the risk.

Some interventions that may have a mild to moderate impact on reducing tearing or the need for episiotomies include the following:

• Perineal massage starting at 34–35 weeks. Women or their partners insert one or two lubricated fingers vaginally about two inches into the vagina and apply pressure downward for two minutes, then on each side for two minutes, for a total of ten minutes at least one or two times a week. Coconut oil, olive oil, and lubricant for sex can all be used. For women in their first pregnancy, perineal massage reduces the risk of tearing that requires stitches by 10 percent and the need for episiotomy by 16 percent. What this means in practical terms is that if your risk of tearing that requires stitching is 50 percent, with massage that risk is now 45 percent. If the risk of episiotomy is 12 percent, with perineal massage the risk is now about 10 percent. Perineal massage may also help reduce pain after delivery, although this association is less clear.

• Perineal massage once you are fully dilated (the second stage of labor) may lessen the severity of the tear, but not the risk of tearing.

• Perineal support, putting a hand or a towel on the perineum and applying gentle pressure, hasn’t been adequately studied to say if this helps protect from tearing or not.

• Warm compresses on the perineum during pushing may reduce third- and fourth-degree lacerations.

• Delivering on your side may have the lowest risk for a tear, but the studies are not high quality, as requiring a woman to deliver in a position for study is not feasible or ethical.

If you do have a tear that enters into the anal sphincter (a third- or fourth-degree tear), a dose of intravenous antibiotics may be recommended at the time of repair as this reduces complications in the first two weeks (8 percent complication rate with antibiotics and 24 percent without).

Pain Control After a Vaginal Delivery

Swelling, bruising, tearing of muscles and skin, need for stitches, and hemorrhoids can all contribute to pain after a delivery. In general, the longer the labor, the greater the pain because there is usually more swelling. Also, fatigue affects pain processing—if you haven’t slept for forty-eight hours and then you pushed for four hours, you will likely have more pain than someone who had a good night’s sleep, woke up, and then had a two-hour labor and pushed for five minutes. Other factors that affect pain include the need for a vacuum or forceps and whether this is your first delivery or not. Genetics and previous pain experiences are also important. Another unique factor is how your baby is doing—the stress of a sick newborn may affect how you process pain.

There are so many individual factors involved in how we process pain it is generally not productive to compare one person’s pain with another’s. You have the pain you have.

Pain after delivery is important to manage because it is important to manage. Many guidelines talk about how important it is for a woman to have pain control so she can breastfeed, but to me that ignores the fact that women need pain control because they need pain control. A healthy mother is the best thing for a healthy baby, so I am of the belief that if we focus on the mother then everything else will fall into place.

Topical anesthetics for the perineum are used in many American hospitals, but they have never been shown to be effective at reducing pain after delivery. Benzocaine, the most commonly used anesthetic for this purpose, is a common allergen, and there are rare causes of it being absorbed and leading to a severe blood condition called methemoglo-binemia. Also, when someone has stitches for other indications—for example, they accidentally cut their hand with a knife—we don’t prescribe or recommend topical anesthetics for pain control. As there is no supportive data for topical anesthetics and there is a risk of causing irritation or even an allergic reaction, give them a pass.

Evidence-based options for pain control after delivery include the following:

• ICE PACKS: Reduce swelling and pain, especially when applied for 10–20 minutes immediately after delivery.

• SITZ BATHS: Getting in a tub of warm water. You don’t have to add anything. You can even empty your bladder in the sitz bath if urine stings when it hits your skin.

• ACETAMINOPHEN AND IBUPROFEN (OR ANY OTHER MEDICATION CALLED A NONSTEROIDAL ANTI-INFLAMMATORY, OR NSAIDS): These are oral medications. Ibuprofen may be slightly better than acetaminophen. Both are safe for breastfeeding.

• KETOROLAC (BRAND NAME TORADOL): An intravenous NSAID that may be especially helpful for women with a third- or fourth-degree laceration.

• HEMORRHOID CARE: Options include astringents like witch hazel, topical steroids, and topical numbing gel or creams like lidocaine (anesthetics are okay to use here). If you have a third- or fourth-degree tear, you should not use suppositories in the rectum as this could disrupt the stitches, so only creams, ointments, or gels.

• PREVENT CONSTIPATION: Straining will hurt, can worsen hemorrhoids, and can tear stitches. Stimulant laxatives such as Senokot or lactulose are the most effective and are safe for breastfeeding. Ducosate sodium is completely ineffective. No study has shown it works, yet for some reason almost everyone recommends it. The biggest issue with a stool softener is people think they are taking something effective when they are not, and then they wonder why they are still constipated.

If your pain is not well controlled in the hospital, a hematoma (a collection of blood that rapidly expands and causes pain—think massive bruise) must be ruled out. A hematoma may need drainage or even surgery so it doesn’t lead to tissue damage or an infection.

It is also important to make sure you can empty your bladder within six hours of delivery. Urinary retention, the inability to empty your bladder, can affect up to 4 percent of women and can injure the bladder if not treated appropriately. Incontinence immediately after delivery is uncommon, so if this happens make sure to tell your doctor or midwife.

If your pain was improving and then takes a turn for the worse, do not assume that it is normal. Check with your doctor or midwife. Potential reasons could be stitches coming apart or an infection.

A word on opioids

Opioids are medications such as morphine, hydrocodone, hydromorphone, or codeine. They are often called narcotics, but that is not a medical term. Some women with a third- or fourth-degree laceration or episiotomy may need a few doses of opioid medications, although it is very important to maximize non-opioid options, as constipation is a known side effect. Opioids are also transferred into the breast milk. An opioid medication is best added in when needed on top of regularly scheduled acetaminophen or NSAIDs.

There is valid concern that opioids are overprescribed to women after delivery. One study tells us that 30 percent of women in the United States received a discharge prescription for opioids after a vaginal delivery, and the number of pills did not vary by size of the laceration or episiotomy. This is overprescribing, and whether it happens because it is a “routine” (not an excuse, just an explanation), doctors and midwives are not educated about other non-opioid medications, women ask for them, or health professionals are trying to prevent follow-up calls for pain is not known.

Studies tell us that 1 out of every 300 women who has never had opioids before delivery will become addicted if she is given a prescription to take home. It takes two doses of an opioid to develop physical dependence, meaning when the medication is stopped, physical symptoms of withdrawal, like feeling unwell and pain, appear. It is easy to mistake symptoms of withdrawal as a false sign that the opioids were helping, and so these symptoms can lead people to restart the opioid medications under the false belief that they need them medically.

Even if you take a prescription of opioids home and never use them, they can still cause harm just by sitting in your medicine cabinet. Children, especially teens, are curious about medications, and taking leftovers found in the medicine cabinet accidentally or on purpose could lead to an overdose or start an addiction.

Lochia

Vaginal bleeding after delivery is called lochia. It starts as bright red and gradually becomes paler in color due to inflammatory cells (a sign of healing in the uterus). Any leftover bits of the lining of the uterus that did not come out with the placenta may also pass with the lochia. Stitches will also add to the discharge as they dissolve.

It is normal to have a heavy, mucusy, blood-tinged, brownish, pretty gross discharge for up to eight weeks after delivery. I remember thinking this was going to go on forever, but it didn’t. You shouldn’t wear a tampon or menstrual cup for this bleeding until you get the all clear from your provider.

Checking In with Health Care Providers After Delivery

The newest World Health Organization (WHO) guidelines recommend four checkups after delivery. At each one, you should be asked about how your perineum is healing, how your bladder is working, and about your lochia, and any tear or stitches should be evaluated to ensure healing is proceeding as expected. The timing for these checkups is as follows:

• Day one (within twenty-four hours)

• Day three (48–72 hours)

• Between days seven and fourteen

• Six weeks

Healing Process: 6–8 Weeks and Beyond

By eight weeks after delivery, many women are still reporting vulvar and vaginal health issues related to delivery. The most common are hemorrhoids (23 percent), constipation (20 percent), and vaginal discharge (15 percent). However, with time, most issues resolve.

If you think your stitches have come out or your wound is falling apart, do not wait for your six-week checkup. Also, if you have an increase in pain, develop a fever, or have a foul-smelling discharge, call your provider or make an appointment. These can be signs of infection.

When to start pelvic exercises

The French system is often held up as a standard for postpartum pelvic floor therapy—the implication online is that there is a nationwide program for pelvic floor rehabilitation at 6–8 weeks postpartum, although according to the 2016 guidelines by the French College of Gynaecologists and Obstetricians (CNGOF), routine pelvic floor physical therapy is not recommended in the absence of incontinence. This is not shade on the French; they are ahead of many countries in this regard, but there does not appear to be a standardized French technique or timing.

Some recommendations for pelvic floor therapy after delivery include the following:

• Pelvic floor physical therapy should not start sooner than two months after delivery, to allow for the tissues to heal and return to baseline.

• Women who have persistent urinary or fecal incontinence at three months after delivery should be offered pelvic floor physical therapy. At least three sessions with an appropriately trained therapist are recommended, as well as home exercises. This improves the speed of recovery but not the outcome—if you do not do the therapy, you will not be worse off incontinence-wise in the long term.

• If you wish to strengthen your pelvic floor, have no symptoms, and are at least two months from delivery, then home exercises (see chapter 10) are a fine, low-cost way to start.

Pain with sex

Most health care providers recommend waiting 4–6 weeks after an uncomplicated vaginal delivery before resuming sex. The open cervix could theoretically increase the risk of infection (although I’m not sure this has been rigorously studied). Also, the tissues need time to heal.

By six weeks after a delivery, 41 percent of women have resumed sex; 78 percent by twelve weeks; and 90–94 percent by six months. Women with a third- or fourth-degree tear are slightly less likely to have resumed sex by six months (88 percent). Having any kind of tear with delivery increases the chance that there will be pain with sex. If you have pain with sex that persists beyond three months after a vaginal delivery, then you should be evaluated.

The three most common causes of painful sex after a vaginal delivery include the following:

• LOW ESTROGEN LEVELS IN THE VAGINA: This is almost exclusively seen in women who are breastfeeding, which can stop ovulation. A small amount of vaginal estrogen cream can solve the problem within a few weeks if lubricant is not sufficient. Once regular menstrual cycles return, your estrogen levels will go up and the vaginal estrogen may be stopped. Using a small amount of estrogen in the vagina is fine while breastfeeding.

• PROBLEMS WITH THE SCAR OR NERVE PAIN: Occasionally, the tissues may heal together in a way that creates a web of tissue at the opening, which can cause pain with penetration. Nerve pain is not common, but when tissues tear or are cut, nerves are injured as well. Prolonged pushing can also stretch nerves.

• MUSCLE SPASM: The muscles of the pelvic floor can become inappropriately tight after delivery. The cause is unknown, but as it can happen after a cesarian section, stretch or injury to the pelvic muscles does not seem to be a requirement. My theory is the rapid withdrawal of progesterone after the placenta is delivered predisposes women to muscle spasms, as progesterone is a potent muscle relaxant. Specialized pelvic floor physical therapy is the treatment and is highly effective.

IS THERE SUCH A THING AS A HUSBAND STITCH? There are stories that circulate about OB/GYNs who reportedly announce at the delivery that they are putting in an “extra stitch” to “tighten” things up for the male partner. In over twenty-five years in OB/GYN, I have heard one older physician many years ago make a bad joke like this, but I never saw him do it. What I have heard are many male partners joking about this in the delivery room and more than a few asking in all seriousness if an extra stitch were possible.

I have asked many OB/GYNs about the “husband stitch,” and uniformly they have all recounted almost identical experiences to my own.

It is important not to confuse a repair that has healed incorrectly or one that was not repaired correctly (mistake or error) with one that was sewn too tightly on purpose. There can be a lot of swelling after delivery, and occasionally this can make a repair technically challenging even for a highly skilled physician. Stitches can occasionally come apart a few days after delivery and then the raw edges heal together incorrectly or in a suboptimal way. There is also, unfortunately, incompetence.

Is it possible that some horrible doctors have done “a husband stitch”? Nothing would surprise me. After all, there are rare pilots who show up drunk and rare reporters who fabricate sources. However, the idea that this is common is not something that I can verify. As someone who specializes in pain with sex, I have not seen a case in over twenty-three years of practice.

If a woman feels too tight after a delivery and/or has persistent pain with sex, it is usually the result of muscle spasm. Narrowing of the vaginal opening after a vaginal delivery due to a poorly healed bridge of skin—either due to the way the tissues healed, complications afterwards, or the quality of the repair—does happen, but in my experience, this is less common than muscle spasm.

Long-term outcomes for sexual function

Studies have looked at whether childbirth affects long-term sexual function. A large study of over one thousand women from an ethnically diverse background showed no association between method of delivery or birth complications and long-term sexual satisfaction.

I found this surprising, as some women definitely do have difficulty recovering sexually after a vaginal delivery.

I suspect the answer is both complex and simple. There are so many variables in sexual functioning, but a caring partner who you love and who is a good lover (meaning the kind of lover you need) is probably the most important. Also, pain with sex and difficulties achieving orgasm are very common before pregnancy and can happen to women who have had C-sections and women who have never been pregnant.

Looking specifically at women over forty, this same study tells us that 56 percent of women had lost interest in sex, 53 percent had sex less than once a month, and 43 percent had low sexual satisfaction. The bad news is that is a lot of women. The good news is the method of delivery didn’t appear to be the driving factor. Sexual function just isn’t about a body part, it’s about you as a whole person.

To put it in perspective, changes in libido, sexual priorities, and satisfaction with their sexual relationship also happen to gay men who adopt a baby. Basically, a baby changes things even when there is no pain from delivery and no pregnancy-related hormonal changes postpartum.

BOTTOM LINE

• During delivery, 44–75 percent of women will tear.

• By six weeks after delivery, 41 percent of women have resumed sex.

• Breastfeeding is associated with pain during sex for the first six months.

• Pelvic floor PT is definitely recommended if you have incontinence; in other situations, Kegel exercises are likely as effective.

• The method of delivery may have a short-term impact on sexual function, but not likely a long-term one.