5 myths about sex in pregnancy and postpartum [interview with Dr. Emily Queenan]

I think it’s time to set the record straight on 5 myths you may have heard about sex in pregnancy and postpartum!

About a year ago I passed around a survey online about sex in pregnancy and postpartum. I received 42 responses from women and 2 responses from nonbinary folks. The stories were wildly varied in experience, but there were a few commonalities across most of the people who filled out the survey that I wanted to get a doctor’s professional opinion on. Then I had the most fortunate luck of meeting Dr. Emily Queenan, a general practitioner, who is as passionate about sex in pregnancy and postpartum as I am, inspiring this article!

Note: Dr. Queenan’s experiences with counseling people postpartum on sexuality were predominantly with women in coupled relationships. The advice below is applicable to all people who have given birth or who are partners of those who have given birth, though the language is gendered at times given Dr. Queenan’s experiences and the available research which does not currently include nonbinary or trans men’s birthing experiences.

1. Pelvic rest means refraining from all types of sex.

Wrong: It just means, “nothing in the vagina,” says Dr. Queenan. Furthermore, people (doctors and patients alike) will often refer to penetrative sex as simply… sex. This can get really confusing really fast. It leaves questions about masturbation, orgasm, oral sex, and hand-play hanging in the air; left for interpretation by the patient. I start here because so many myths can get tangled in unclear language or medical jargon. Similar to what doctors mean when they ask their patients if they’re sexually active, “what we’re really getting at is penis-in-vagina-sex,” which Dr. Queenan points out she needs to be deliberate about.

So! If your doctor says you need to be on pelvic rest, it doesn’t mean no masturbation, oral sex, hand-play, snuggling, breast play, grinding, rubbing, kissing, or orgasms. It just means no penetration in the vagina. If you’re ever unsure what your doctor is saying, ask for clarification. If your doctor wants you to abstain from orgasms and other types of sex as well, I’d encourage you to ask for the medical evidence-based reason.

2. You shouldn’t have sex for the first 6 weeks postpartum, but after 6 weeks you’re “good to go.”

This was by far the most common experience expressed in the survey I distributed: my doctor said I was good to go at the 6 week follow-up, but when we tried to have penetrative sex it was so painful. To make matters more confusing, a few of the respondents started having sex well before the 6 week mark with no problems. What does it all mean?

“I recommend certainly no intercourse [penetrative sex] in the first two weeks after having a baby because that’s really when your cervix is healing and you’re coming back together from the birthing process,” says Dr. Queenan. Okay, perhaps some of respondents in my survey were having other kinds of sex and the research clearly shows women are engaging in masturbation and hand-play long before 6 weeks (Cappell, MacDonald, & Pukall, 2016; Hipp et al., 2012; Sydow, 1999).

At the 6 week mark, Dr. Queenan never simply says you’re good to go! With regards to sex, “it’s a process,” she explains. Setting realistic expectations for her patients is important to Dr. Queenan, “the first several times of penetration there will be burning and that’s because the tissue has really stretched and now is healing and it’s still in the healing process.” She also explains that the vagina is going to be drier than usual, so the use of lubricants and vaginal moisturizers are going to be really important for most people. Starting off with positions like the birth person on top helps “control the depths and frequency and the speed of penetration.” And of course, be sure to include “lots of really good communication so that [people] can say ah! That’s not working well for me or if that is.”

By the 3 to 6 month period, sexual activity of any kind really shouldn’t be painful or uncomfortable anymore, and if it is, heading back to your doctor for next steps is a good idea. Dr. Queenan really likes working with pelvic physiotherapists (as do I!). “They work magic! Especially when you have someone with an extensive tear with scar tissue, or even if it’s not that extensive, it’s just the way their body responds or heals and they have scar tissue– a pelvic physiotherapist can make a huge difference in a woman’s life to heal that pain with intercourse– that dyspareunia.”

There you have it! Six weeks is an arbitrary number based on a narrow definition of what sex is. Furthermore, it does not accurately reflect the variability of individual’s experiences. Let’s move onto the next myth…

3. Sex during pregnancy can hurt the baby or cause a miscarriage.

Not only is this untrue, but many of the respondents in the survey were told by their doctors to refrain from having sex in the first trimester if they had a history of miscarriage. “Professionally I’m really surprised by that advice… I’m surprised any doctor would give that advice.” Additionally, a review of sex and miscarriage by Andrew Moscrop (2012) concluded that no scientific research has been conducted to validate this concern.

Dr. Queenan explains first trimester miscarriages are generally thought to be due to “a major genetic problem or the body’s ways of stopping a pregnancy that is not going to develop healthily… it can be the uterine environment itself somehow, but that has certainly nothing to do with sex itself. In all my medical training I can’t think of any reason why a woman would need pelvic rest in the first trimester.”

Later in pregnancy there are some instances where pelvic rest (remember this means no penetration only) may be recommended: risk of pre-term labour, placenta previa, placental abruption, and cervical insufficiency.

For risk of pre-term labour a doctor may recommend pelvic rest because of concerns about the release of prostaglandins (also found in sperm) from stimulating the cervix. Dr. Queenan admits she doesn’t know if there is data to support the efficacy of pelvic rest to lower the risk of pre-term labour, “but I don’t know that it isn’t there, I just don’t know the data.”

I wondered, does this mean the pregnant person can still have an orgasm through masturbation or other sexual activity without penetration?

“That’s a great thought… Truth be told it’s not usually specifically addressed, but physiologically I would not have concerns about a woman masturbating or any sort of intamacy reaching orgams because, sure, you’re having uterine contractions at that point but they’re not the contractions that lead to labour… it is increasing oxytocin… it’s certainly not a common reason for why a women went into preterm labour… I think it depends… I think that that would be a reasonable conversation and that for some pregnancies it would make sense to abstain even potentially orgasms.”

It’s difficult to reach any kind of confident conclusion when there’s little or no research to go on. Perhaps a doctor’s tendency to play it safe and recommend no sexual activity is based more on what we don’t know than what we do. And who can blame them? They have a vested interest in you and your baby’s well-being. Ultimately, it’s your body and your choice to make a decision that feels right for you with the knowledge that you have.

“The other reason why we might commonly recommend pelvic rest is for what’s called placenta previa… if she’s not having any bleeding I haven’t found any reason that we need to say keep her on pelvic rest for the duration of her pregnancy but if she’s had some episodes of bleeding, some disruption of the placenta there as it covers the os [cervical opening], we would often recommend pelvic rest to avoid further disruption of the placenta… and that would really just be for pelvic rest; I can’t fathom a reason why we’d be concerned about orgasm.” Again, Dr. Queenan admits there’s not a lot of evidence-based research for this advice as these are difficult things to study.

With placental abruption you’ll likely be pretty uncomfortable and hanging out at the hospital. It’s unlikely you’ll even want to have sex. It’s rarer still to have a chronic abruption where they will send you home. In any case, if you have placental abruption and it’s really turning you on, it’s best to hold off until things get back to normal given the severity of this condition.

Finally, cervical insufficiency may be cause for pelvic rest, as well. “If a woman has found to be having a shortening cervix or even progressing to actual dilation… pelvic rest would be indicated just to avoid disrupting that cervix.”

Having said all that, it’s important to remember for healthy pregnancies, “There is absolutely nothing that [consensual] sex can do to hurt a baby– a healthy pregnancy. The baby is so well insulated in the amniotic fluid, in that amniotic sac! And if anything [the baby] enjoys a gentle rocking!… there’s absolutely nothing that could even be a tiny bit bad about sex in pregnancy including all the way up until term and your baby is a totally developed baby inside of there… If anything there is just nice good squeezing and contracting and rocking– all really good stuff for babies.”

4. My vagina/vulva is permanently damaged because of birth!

Changes in vaginal or vulva sensation were commonly reported in the survey, ranging from intensely sensitive to extremely dulled or numb. What was unclear for a lot of a people was whether or not these changes were permanent.

“Superficial nerve damage is super super common,” Dr. Queenan explains. C-sections will also commonly cause numbness over the abdomen that can last up to 9 months, “just as the nerves naturally regrow and come together again.”

Dr. Queenan also notes that it’s important to keep some things in mind about the time it takes the body to heal. She recommends in the first 3 months gently supporting the body to heal, “but without actively engaging in therapy.” By 6 months things should be completely healed– “if they’re not, make sure you’re seeing your doctor and talking about what you’re feeling and next steps.” This could include a referral to a pelvic physiotherapist or a pain clinic.

Dr. Queenan would never say with full confidence this will be 100% fixed and go back to normal, but, “I would say we’ll take different strategies… and I’m confident we’ll be able to help you feel better, this does not have to be the way you live the rest of your life.”

5. Sex isn’t important postpartum and you should just focus on the baby.

Parenthood is hard. There is no shortage of research depicting the decline in relationship satisfaction in postpartum years. Dr. Queenan has found that “so many times intimacy falls away because the whole couples life is centered around the baby… certainly this isn’t about guilting a woman into having sex even when she’s not in the mood, but it’s to say [speaking to her patient] that this is important, intimacy is important, and cultivating this is important in your relationship and come see me if it’s a problem.”

This perspectives comes from Dr. Queenan not only as a doctor, but also a mother. “I didn’t really get that until maybe I started having my own kids and I got into the depths of my family medicine practice.”

But some women I’ve spoken to have felt that when it comes to intimacy postpartum they’re the ones doing all the emotional labour/work to keep the relationship strong. With all that exhaustion and frustration, it’s no wonder sex gets put on the backburner. When and with whom is the partner’s 6 month postpartum follow-up, I wonder?

“I guess that’s where I try to say, intimacy is important, sex is important, and if you have concerns about it come see me… what’s going on at home? Is it because her husband is over-tired, over-stressed, over worked and has nothing more to give at home… is it because he’s good at his work job and when he comes home he feels incompetent so he’s resigned?… it’s pretty common.” In these cases, I would recommend to clients the benefits of couples counseling.

Each partner needs to participate in maintaining the relationship. If one partner is doing all of the emotional labour, they’re definitely going to get burnt-out and sex probably won’t seem all that enticing. In a study by Woolhouse, MacDonald, & Brown (2012) they found couples who weathered the transition into parenthood worked as a team, spent time together away from their kids, and agreed on priorities.

It’s worth working on together. It’s so easy to let our romantic relationships go by the wayside when parenthood is so hard, “by the time the baby is a toddler and the couple has had sex [maybe] three times over the last year, and a couple of them were painful, you can forget why you like one another.” Well said.

There you have it! Five common myths put to rest. It’s so easy to feel anxious and scared about doing the wrong thing during pregnancy and postpartum. Especially if you’ve experienced multiple miscarriages and have been trying to become pregnant for several years. It’s harder still on a subject like sex, which can make both doctors and patients uncomfortable to address. But it’s so crucial to be having these conversations if only not to feel so alone, because you’re not alone.

If you don’t have trouble talking about sex, maybe bring it up at your next mommy meeting or queer prenatal class! You could start it with, “hey, I was reading this really interesting article by sex educator Tynan Rhea…” (shameless plug). You might get a few blank stares or you might get an enthusiastic room dying to talk about it. In my experience, more people want to talk about sex than not, they just don’t know who they can turn to.

Let’s turn to each other and keep this conversation going!

Dr Emily Queenan is from Rochester, NY, USA where she had a thriving solo family medicine practice that provided full spectrum family medicine and maternity care from 2009 until 2014; she closed it in May 2014 when she decided that she could no longer endure the administrative burdens of the American insurance system. In the months that followed, she started to explore a move to Canada in order to practice within the country’s single-payer universal health insurance system, and moved with her family to Midland, ON in August 2015. She now has a full spectrum family medicine with OB practice, Queenan Family Medicine & Maternity Care in Penetanguishene, ON.