Sex in Pregnancy

There are a lot of myths and fears about having sex in pregnancy. Sex in pregnancy is perfectly safe and a healthy element to a relationship. Penetrative sex specifically will not harm your baby in any way; the baby will not come into contact with your partner’s penis/ finger/ any object as the cervix is between the vagina and the uterus.

Some women find that they have a greater desire for sex during pregnancy due to changes in hormones (oestrogen and progesterone) and increased blood flow to their breasts and genitals. Vaginal secretions can also increase in pregnancy due to hormonal changes. Equally, some people will not feel like having sex when pregnant or at certain times during their pregnancy for a multitude of reasons: discomfort, changes in the relationship with their changing body, stress, feeling tired or nauseous (to name a few). Listen to your body and do what feels good.

When you orgasm there is a surge of the hormone oxytocin. This is the same hormone that makes your uterus contract in labour. However, this does not mean having sex will make you go into labour if your body is not ready to. There is no evidence that having sex in pregnancy causes premature labour. You may experience what are known as ‘Braxton Hicks’ contractions after orgasm. The muscles in the uterus tighten and go hard. It can be a strange sensation so if worried try to use relaxation techniques to relax until it passes.

It is safe to use a vibrator or sex toys in pregnancy. If you have been told specifically to avoid penetrative sex then this applies to using toys as well. Follow the same rules that you would when using these in a non-pregnant state! Wash after use, read the instructions.

If having sex with a new partner it is important to still use condoms/ barrier methods to avoid sexually transmitted infections, as these can be particularly dangerous for an unborn baby.

When it is not recommended to have sex in pregnancy:

• If you have had any heavy vaginal bleeding. Having sex may cause further bleeding or may be related to a low-lying placenta.
• If your waters have broken as it may increase the risk of infection. Remember there is a mucous plug that seals the cervix and keeps your baby’s environment sterile, so if your waters have broken this protection is no longer present.
• If you have a history of cervical dysfunction or weakness (when the cervix struggles to stay closed during pregnancy). You would only know this if you have experienced this in a previous pregnancy.
• If you don’t want to have sex!

Speak to your midwife or doctor if you have any questions or concerns about having sex in pregnancy.

A note on consent

Within healthcare, it goes without saying that consent is of upmost importance when you are giving and receiving care. Most of us have seen the ‘consent is like a cup of tea’ video… if not here it is. But consent is not as simple as yes or no (don’t lose me here… I promise it is still simple!)

Consent is only proper consent if it is informed. Informed consent involves receiving all the information you need to make a decision about whether what is being offered/proposed is the right choice for you. It is about hearing the risks and benefits of accepting or declining something. If we stick with the tea idea, it would be like offering someone a cup of tea, … then passing it to them without the warning that it is really hot and could burn them.

Informed consent involves fully exploring the thing that is being offered, and this should include the other options available to you as well. So you have been offered tea, but what if you don’t like tea? You’ve never had tea before, so how do you know what it tastes like? Or maybe you just don’t want tea. Well, turns out there is coffee and hot chocolate available too! (the tea analogy is a real winner…)

In regards to pregnancy, everything offered to you (as routine as it may seem) should still be presented as a choice you are making. This relates to blood tests, scans, screening etc. Nearly all of the time these are things that are recommended to promote the health and wellbeing of you and your baby. But not every intervention is right for everyone, and it is ok to decline aspects of care if you feel that is the right decision for you.

Informed consent applies to any interaction you have with a healthcare practitioner. There is no one size fits all approach, and only you can make decisions relating to your body.

 

 

Your Pelvic Floor and how to exercise it

What is the pelvic floor?

The pelvic floor is the name used to refer to the layer of muscles that support the pelvic organs (bladder, bowel and uterus). It is essentially a supportive hammock that stretches from the pubic bone at the front to the tailbone (coccyx) at the back, and from one sitting bone to the other (side to side). Imagine it as a trampoline made of firm muscle that the organs sit on top of. The urethra, vagina and anus pass through the pelvic floor, and the pelvic floor helps to keep these passages closed. There are also circular muscles within the urethra and anus known as sphincters, keeping them closed until you need to pass urine or open your bowels.

Why is it important for these muscles to stay strong?

Keeping these muscles strong will help to reduce your risk of urinary incontinence later in life. This is the unintentional leaking of urine due to weakening of the muscles. A common type is called ‘stress incontinence’ where you leak urine at times when your bladder is under pressure, for example when you cough, sneeze or laugh. The pelvic floor muscles also support the vaginal wall and can prevent pelvic organ prolapse (POP). This is where the bladder, rectum or uterus protrudes/bulges into the vagina as the muscles holding them in place are weakened. As you can imagine this can be very uncomfortable and effect your sexual functioning.

Doing these exercises in pregnancy combined with perineal massage has been found to significantly lower the rate of episiotomies and severe perineal trauma; with a higher rate of women having an intact perineum (no tears at all) in comparison to women who didn’t perform the exercises (study here for the geeks).

These exercises are important for everyone, not just in pregnancy and after having a baby. There is some evidence to suggest that these exercises can improve sexual sensation.

How do I exercise these muscles?

It’s important to make sure you do these exercises in the right way, so make sure that you concentrate whilst doing them. First tighten (squeeze) the muscles around the back passage, as if you are trying to stop yourself passing wind. Whilst you hold this squeeze, tighten around the vagina and urethra, as if you’re trying to stop yourself from passing urine. It should feel like a ‘squeeze and lift’ inside. After each ‘squeeze and lift’ make sure you fully relax your muscles by letting them rest back to their starting level. (From the ‘Squeezy’ NHS app)

Try to breathe normally when you perform these exercises. You may feel your tummy muscles gently working, but the muscles in your thighs and buttocks should be relaxed.

Practice ‘slow’ exercises by holding the squeeze for a few seconds, gradually building in length as your pelvic floor muscles get stronger. I like to visualise I am going up in a lift: starting on the ground floor you engage the pelvic floor muscles. Imagine that with every floor that you go up in the lift you squeeze the muscles slightly more until you reach the ‘top floor’, then when you have reached your limit gently release the muscles as you return to the ‘ground floor’.

Don’t practice your exercises when actually passing urine as this can effect the flow of the urine and may increase the likelihood of getting a urinary tract infection.

 

Useful contacts relating to pelvic floor, bladder and bowel problems:

pogp.csp.org.uk (Pelvic Obstetric and Gynaecological Physiotherapy)

www.bladderandbowel.org (Bladder and Bowel Community)

www.womens-health-concern.org

www.cobfoundation.org (for cystitis and overactive bladder)

www.birthtraumaassociation.org.uk

‘Why am I so constipated in pregnancy?’ And going for your first poo after birth…

I have given an overview of the different hormones at play during your pregnancy before in this post. One of the hormonal key players for many of the weird and wonderful joys of pregnancy is progesterone. Progesterone relaxes smooth muscle in the body. It acts in this way to prevent the uterus contracting, and therefore labour starting, before the baby is ready to be born. But this also has a knock on effect on other smooth muscle in the body, and predominantly the digestive system as the oesophagus, stomach and intestine are made up of smooth muscle. Peristalsis (wave like muscular contractions) is the movement through which food is moved through the digestive tract, and the high level of progesterone slows this process down in pregnancy. Cue: acid reflux and heartburn, burping, bloating, gas and constipation. All of the fun.

Tips to avoid constipation:

• Drinking plenty of water. Hot drinks such as herbal teas, particularly peppermint and fennel can help. Avoid caffeine.
• Eating foods high in fibre (wholegrains, fresh fruit and vegetables, pulses)
• Gentle exercise (swimming, walking, yoga)

You may be taking iron supplements in pregnancy if you have become anaemic (low iron levels). These can contribute to constipation, especially if you are taking a high dose of iron. It may be necessary to take a medicine to soften your stool, so speak to your GP if you are suffering from constipation despite following the above tips.

Pooing after the birth

You may not have even given this a thought prior to the birth. Why would you? All your preparation has been geared towards a little human arriving earthside. And then that happens, and life goes on, meaning you have to poo again… but no one told you about the post-birth constipation! In whatever way your baby has been born (vaginal or C-section), you are likely to have some constipation following the birth.

There are a few reasons for this:

• You are still recovering from the effects of progesterone in the pregnancy
• You are likely to have emptied your bowels during labour
• After the birth your body goes through ‘diuresis’, which is an increased production of urine. This is because you had increased fluid (blood volume) in pregnancy, which is no longer needed. This sudden loss of fluid can leave you a bit dehydrated
• You may have received certain drugs, such as pethidine or morphine, which can cause constipation
• You may be less mobile if you have had a C-section which can slow down digestion
• If you have had a c-section your bowel may have been disturbed in the process

It is common to feel nervous and fearful of going to the toilet after birth. You will likely have some bruising and may have had stitches following a vaginal birth, or have a C-section wound. All of these can make you feel anxious and fearful of doing a poo as you are understandably scared that ‘pushing’ to open your bowels will a) hurt and b) cause stitches to undo. First of all, you will not open any stitches by going to the toilet. Sutures are strong and designed to hold tissue together until it has healed. The area may feel sore and swollen, and you can take pain relief such as paracetamol and ibuprofen. Second, you should not be straining to open your bowels as this can lead to or worsen existing haemorrhoids (also known as ‘piles’, a swelling containing enlarged blood vessels inside or around the anus). Saying this, haemorrhoids are common in pregnancy due to the increased pressure on your pelvic blood vessels and because of our good friend progesterone relaxing your bloods vessels (they are made of smooth muscle too). Try going to the toilet with your feet raised slightly off the floor, using a stool or a stack of books, mimicking a squat position. This helps the muscle that holds our poo in when we are standing to fully release and makes it easier to empty the rectum.

So there we have it, hopefully! If in doubt: FLUIDS, FIBRE, (gentle) MOVEMENT!

Perineal Massage

I have done a blog post previously on perineal trauma that can occur at birth, and made some suggestions on how to reduce this risk as much as possible in labour and when birthing your baby. This post is all about something that you can do during pregnancy in preparation for the birth of your baby, to reduce this risk even further. There are no secrets here, as it says on the tin, it involves massaging your perineum (the area between the vaginal opening and the anus). It is a good idea to start doing this regularly, a few times a week from around 34 weeks of pregnancy.

Perineal massage is an evidence-based way to significantly reduce your risk of sustaining a perineal tear that requires suturing, if you are having your first baby. Women who perform perineal massage are also less likely to have an episiotomy performed at birth. An episiotomy is a cut performed at birth between the vagina and the anus to increase the vaginal opening. It is not routinely performed in the UK, as research suggests it is better to allow this area to tear naturally. However, sometimes it is performed if there are signs that the baby is in distress and needs to be born as quickly as possible, or it is occasionally recommended to prevent a more severe tear occurring. An episiotomy is the equivalent of a second degree tear (a tear that involves the vaginal and/or perineal muscle, but none of the anal sphincter), and can be repaired by the midwife or doctor.

Performing the massage

Performing perineal massage does involve engaging with your body in an intimate way. For some people, this will be an unintimidating and relaxing exercise. For others, this may be the first time you have touched your body in this way. It can be a really empowering experience to get to know our bodies and develop an understanding of the sensations you are likely to feel during birth. Some people may choose to incorporate perineal massage into sexual touch, either on their own or with their partner. For others, they may feel more comfortable framing the massage as a non-sexual exercise. It is entirely up to you what you feel most comfortable with. The massage may feel a bit strange to start and take a bit of getting used to, but it should not be painful.

How to do it

1. Wash your hands with soap and water and get comfortable. I suggest putting a towel down on your bed and lying down against some comfy cushions with your bottom half bare.
2. Have some natural oil such as almond or olive oil to hand, or a lubricant of your choice.
3. If doing the massage yourself you should use your thumb. Insert your thumb about 3-4cm inside your vagina. If you have a partner assisting you to perform the massage they should use two fingers.
4. Apply firm pressure downwards with your thumb towards your anus. Massage the skin from side to side in a sweeping motion, whilst continuing to push downwards.
5. You can also use two thumbs and sweep downwards and outwards. Imagine that your vaginal opening is a clock face. Your thumbs start at 6 o’clock, then stretch outwards and upwards towards 3, applying pressure.

Some clients have told me they found it quite tricky performing perineal massage on themselves during the later stages of pregnancy. Try not to worry if you are finding it a bit difficult to perform the massage 100% effectively. You cannot do it ‘wrong’ as such, it may just take a bit of practice and getting used to!

 

Thank you to the ever-wonderful Jasmine Hortop for the most amazing perineal gif known to WO-man! Check her work out here… www.jasminehortop.co.uk