So you’ve grown a baby over the last 9-10 months. You birthed that baby. You are halfway through the 4th trimester, and you are cleared by your doctor to resume business as usual. You stopped bleeding a few weeks ago (maybe). You are hopefully in somewhat of a groove learning how to breastfeed without pain (if you decided to go that route). Whether it is your first or you have multiple, there is always an adjustment in stepping to a new role of a Mom of 1, 2, 3...7, 8. There is a good chance your body still doesn’t feel like your own. Business as usual?! How is that even possible?!
This is one of the most common conversations and issues we deal with in pelvic floor therapy: moms who don’t feel ready, or do feel ready but have pain when trying to be intimate with their spouse. Let’s go through the basics of what we discuss in the clinic in regards to sex after birth. We will also give you some hints to help you determine if you would benefit from an evaluation (Clue: every woman would benefit from an evaluation after birth. It’s standard care, just as prenatal visits, in other countries).
It is SUPER important to wait until you’ve completely stopped bleeding before you attempt intercourse. You want to make sure the cervix has completely closed to reduce risk of infection. This can take anywhere from a few days to the full 6 weeks in some women.
I often will tell my patients to think of sex after birth as merely transactional. Of course this doesn’t sound romantic, but there can be so much angst and anxiety built up around anything being touched or seen “down there” after birth. If you don’t expect it to be great, you can be open to see how your body is feeling.
“Am I in pain?”
“Is there any pulling around the stitching?” (If that happened to you)
“How does it differ from sex before?”
“Am I able to do a kegel?”
If you are experiencing any of the above scenarios, these are extremely treatable with some manual therapy and targeted exercises/stretches. You also may be surprised to find that it feels fine. It is okay to be objective and in your head for a little while. It’s also important to be gracious and kind to yourself. You just delivered a human a little over a month ago. Your body is a TEMPLE, girlfriend. Be proud!
Go SLOW. You are in control. I will often recommend “Mom on top” the first few times so you can control the speed and depth that feels comfortable for you. Spooning is also great to limit the depth of penetration. If something feels off, see if you can get an appointment with a pelvic floor therapist. Oftentimes, scar tissue mobilization and addressing any internal trigger points can make all the difference. Assessment and techniques used during pelvic floor evaluations are gentle and performed with a finger; odds are if soft tissue dysfunction or pain is discovered with us, a penis or toy is sure to cause discomfort.
LUBE IS OUR FRIEND! This may or may not have been part of your routine prior to birth, but we recommend having it handy for the first couple of times at least. You may find that you don’t need it, but it’s important to remember your hormones are still adjusting. In the postpartum period, especially if breastfeeding, estrogen levels are low. Estrogen helps to lubricate us and bulk up vaginal tissue and pelvic floor muscles, so you may need to substitute for a bit.
Last but not least, YOU ARE NOT BROKEN. This is NOT A NEW NORM. It’s SO important to control the head talk in the first few months after birth. If sex feels great, AWESOME. If it feels like s***, remember to be objective with yourself and talk to yourself like you would a friend. Be curious instead of judgmental. “It’s probably a tight muscle that needs to be released.” or “I’m not sleeping great and my hormones are all over the place, it will balance out with time.” These can be much more affirming and positive than thoughts like “My body is broken.” And just know there is help out there if you aren’t feeling 100%.
Hints that you may benefit from a pelvic floor therapist:
If you are having pain whatsoever, it’s worth having an evaluation. Many people have a misconception that the pelvic floor is loose and “stretched out” after birth. In reality, some women actually have a lot of muscle spasms which can become tight and painful. It could be related to a tear and stitch that developed scar tissue buildup. It could also be that the pelvic floor stretched too fast during pushing which caused the muscles to go into guarding mode.
If you had a C-section. Period. There is a big misconception that women who delivered via Cesarean Section don’t need pelvic floor rehab. Your deep core consists of your pelvic floor muscles, breathing muscle (diaphragm), deep abdominals (transversus abdominis) and erector muscles in the spine (low back). During a C-section layers of the abdomen, including the deep abdominals, are cut into and then stitched closed. We know, anywhere in the body, that muscles that undergo surgery also undergo a guarding and healing phase, altering the dynamics and function of whatever muscle group. It is common to have sensitivity and tightness near the scar that needs to be desensitized and mobilized. Guarding and dysfunction at the abdomen often leads to change in breathing and lifting mechanics, as well as compensation and overuse of surrounding structures.
If you have any sensations of heaviness or “something in the way” with sex, you may have some prolapse. Prolapse is the descent of one or more pelvic organs and can include the bladder, uterus, urethra and rectum. This can sound and feel scary, but it’s important to remember your body is still healing and it can definitely be improved with targeted rehabilitation.
If you are having difficulty performing a kegel, or contracting your pelvic floor as you would to hold in a fart, it would be helpful to understand why. Sometimes it is just related to inflammation and general weakness after birth. Other times it is related to the muscle spasms we mentioned above. Too tight muscles don’t function well. This is why “just doing your kegels” isn’t the best advice or a catch-all for everything. In someone who already has a high tone pelvic floor, kegels can actually worsen pain or urinary incontinence.
A great resource we love and share with our patients is “Reviving Your Sex Life after Baby” by Kathe Wallace. She is one of the founders of the Herman and Wallace Pelvic Rehabilitation Institute and is a pioneer of pelvic rehabilitation and women’s health physical therapy.
Dr. Carly Gossard PT, DPT, OCS, PRPC
Pelvic Floor Physical Therapist
Owner, Empowered Pelvic Health