Lawrence Leeman

Sex After Childbirth Postpartum Sexual Function

Pregnancy and childbirth bring many changes to the health and well-being of new mothers. Postpartum sexual health is a common concern that is often not discussed during prenatal or postpartum care and has received little attention from either clinicians or researchers. In this article, we review current theories of female sexual response, the epidemiology of postpartum sexual dysfunction, and the use of screening tools to identify women with sexual health concerns. Specifically, we present a review of published data regarding the effect of mode of delivery, perineal lacerations, postpartum depression, and breastfeeding on postpartum sexual activity and function. Finally, suggestions for how to screen for and approach the treatment of postpartum sexual problems are presented.

Does Spontaneous Genital Tract Trauma Impact Postpartum Sexual Function

Changes in sexual function are common in postpartum women. In this comparative, descriptive study, a prospective cohort of midwifery patients consented to documentation of genital trauma at birth and assessment of sexual function at 3 months postpartum. The impact of spontaneous genital trauma on postpartum sexual function was the focus of the study. Trauma was categorized into minor trauma (no trauma or first-degree perineal or other trauma that was not sutured) or major trauma (second-, third-, or fourth-degree lacerations or any trauma that required suturing). Women who underwent episiotomy or operative delivery were excluded. Fifty-eight percent (326/565) of enrolled women gave sexual function data; of those, 276 (85%) reported sexual activity since delivery. Seventy percent (193) of women sustained minor trauma and 30% (83) sustained major trauma. Sexually active women completed the Intimate Relationship Scale (IRS), a 12-item questionnaire validated as a measure of postpartum sexual function. Both trauma groups were equally likely to be sexually active. Total IRS scores did not differ between trauma groups nor did complaints of dyspareunia. However, for two items, significant differences were demonstrated: women with major trauma reported less desire to be held, touched, and stroked by their partner than women with minor trauma, and women who required perineal suturing reported lower IRS scores than women who did not require suturing.

The Validity of Phosphatidylethanol in Dried Blood Spots of Newborns for the Identification of Prenatal Alcohol Exposure

BACKGROUND Accurate identification of prenatal alcohol exposure (PAE) in the newborn period offers an opportunity for early identification of children at risk of future neurocognitive problems and the implementation of interventional approaches earlier in life. PAE newborn screening by measuring phosphatidylethanol in dried blood spot (PEth-DBS) cards is feasible, logistically easier, and more cost-efficient compared with other biomarkers. However, the sensitivity and specificity of this method have yet to be established. METHODS This prospective cohort study examined validity of PEth-DBS among 28 infants with PAE and 32 controls relative to maternal self-report and other biomarkers. Pregnant women were recruited from a University of New Mexico clinic and followed to early postpartum period. The composite index, which was based on self-reported measures of alcohol use and allowed to classify subjects into PAE and control groups, was the criterion measure used to estimate sensitivity and specificity of PEth-DBS. RESULTS The study included large proportions of patients representing ethnic minorities (7.4% American Indian, 81.7% Hispanic/Latina), low education (54.2% <high school), and unplanned pregnancy (90.0%). No differences in sociodemographic characteristics, smoking or illicit drug use were observed among the study groups. The sensitivity of maternal biomarkers (gamma glutamyltranspeptidase [GGT], % carbohydrate-deficient transferrin [%CDT], urine ethyl glucuronide [UEtG], urine ethyl sulfate [UEtS]) was low (<15%) reflecting a moderate chronic or intermittent binge pattern of drinking in this cohort. PEth-DBS demonstrated 100% specificity and the highest sensitivity (32.1%) compared with other biomarkers. A battery consisting of maternal direct ethanol metabolites (UEtG, UEtS, PEth) and newborn PEth-DBS increased sensitivity to 50% without a substantial drop in specificity (93.8%). CONCLUSIONS Newborn PEth-DBS is a highly specific biomarker and can facilitate accurate detection of PAE in conjunction with other biomarkers. Minimal invasiveness, ease of storage and transportation of DBS cards, absence of postcollection synthesis, cost savings, and potential integration with routine newborn screening are all unique advantages of this method.

Postpartum perineal pain in a low episiotomy setting: association with severity of genital trauma, labor care, and birth variables.

BACKGROUND Perineal pain is common after childbirth. We studied the effect of genital tract trauma, labor care, and birth variables on the incidence of pain in a population of healthy women exposed to low rates of episiotomy and operative vaginal delivery. METHODS A prospective study of genital trauma at birth and assessment of postpartum perineal pain and analgesic use was conducted in 565 midwifery patients. Perineal pain was assessed using the present pain intensity (PPI) and visual analog scale (VAS) components of the validated short-form McGill pain scale. Multivariate logistic regression examined which patient characteristics or labor care measures were significant determinants of perineal pain and use of analgesic medicines. RESULTS At hospital discharge, women with major trauma reported higher VAS pain scores (2.16 +/- 1.61 vs 1.48 +/- 1.40; p < 0.001) and were more likely to use analgesic medicines (76.3 vs 23.7%, p = 0.002) than women with minor or no trauma. By 3 months, average VAS scores were low in each group and not significantly different. Perineal pain at the time of discharge was associated in univariate analysis with higher education level, ethnicity (non-Hispanic white), nulliparity, and longer length of active maternal pushing efforts. In a multivariate model, only trauma group and length of active pushing predicted the pain at hospital discharge. In women with minor or no trauma, only length of the active part of second stage labor had a positive relationship with pain. In women with major trauma, the length of active second stage labor had no independent effect on the level of pain at discharge beyond its effect on the incidence of major trauma. CONCLUSIONS Women with spontaneous perineal trauma reported very low rates of postpartum perineal pain. Women with major trauma reported increased perineal pain compared with women who had no or minor trauma; however, by 3 months postpartum this difference was no longer present. In women with minor or no perineal trauma, a longer period of active pushing was associated with increased perineal pain.

Patient-Choice Vaginal Delivery?

Patient-choice cesarean delivery is increasing in the United States. The American College of Obstetricians and Gynecologists supports this option, citing ethical premises of autonomy and informed consent, despite a lack of evidence for its safety. This increase in patient-choice cesarean delivery occurs during a time when women with a breech-presenting fetus or a previous cesarean section have fewer choices as to vaginal birth. Patient-choice cesarean delivery may become widely disseminated before the potential risks to women and their children have been well analyzed. The growing pressure for cesarean delivery in the absence of a medical indication may ultimately result in a decrease of women’s childbirth options. Advocacy of patient-choice requires preserving vaginal birth options as well as cesarean delivery.

Effect of Progestin Compared With Combined Oral Contraceptive Pills on Lactation: A Randomized Controlled Trial.

OBJECTIVE: To estimate the effect of progestin-only compared with combined hormonal contraceptive pills on rates of breastfeeding continuation in postpartum women. Secondary outcomes include infant growth parameters, contraceptive method continuation, and patient satisfaction with breastfeeding and contraceptive method. METHODS: Postpartum breastfeeding women who desired oral contraceptives were randomly assigned to progestin-only and combined hormonal contraceptive pills. At 2 and 8 weeks postpartum, participants completed in-person questionnaires that assessed breastfeeding continuation and contraceptive use. Infant growth parameters including weight, length, and head circumference were assessed at 8 weeks postpartum. Telephone questionnaires assessing breastfeeding, contraceptive continuation, and satisfaction were completed at 3–7 weeks and 4 and 6 months. Breastfeeding continuation was compared between groups using Cox proportional hazards regression. Differences in baseline demographic characteristics and in variables between the two intervention groups were compared using &khgr;2 tests, Fisher exact test, or two-sample t tests as appropriate. RESULTS: Breastfeeding continuation rates at 8 weeks (progestin-only 63.5%; combined hormonal 64.1%), contraceptive continuation, and infant growth parameters did not differ between users of progestin-only and combined hormonal contraceptive pills. Infant formula supplementation and maternal perception of inadequate milk supply were associated with decreased rates of breastfeeding in both groups. CONCLUSION: Choice of combined hormonal or progestin-only contraceptive pills administered 2 weeks postpartum did not adversely affect breastfeeding continuation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01465022. LEVEL OF EVIDENCE: I

Do Unsutured Second-Degree Perineal Lacerations Affect Postpartum Functional Outcomes?

Background: To compare the postpartum pelvic floor function of women with sutured second-degree perineal lacerations, unsutured second-degree perineal lacerations, and intact perineums. Methods: A prospective cohort of nurse-midwifery patients consented to mapping of genital trauma at birth and an assessment of postpartum pelvic floor outcomes. Women completed validated questionnaires for perineal pain and urinary and anal incontinence at 12 weeks postpartum and underwent physical examination to assess pelvic floor strength and anatomy at 6 weeks postpartum. Results: One hundred seventy-two of 212 (80%) eligible women provided follow-up assessment data at 6 or 12 weeks postpartum. Women with an intact perineum (n = 89) used fewer analgesics (P < .002) and had lower pain scores at the time of hospital discharge than women with second-degree lacerations (sutured, n = 46; unsutured, n = 37; intact, n = 89) (P ≤ .02). The sutured group was more likely to use analgesics (52%) than the unsutured (35%) or intact (23%) groups at time of hospital discharge (P < .002), although pain scores were not different between sutured and unsutured groups. Postpartum reports of urinary or anal incontinence, sexual inactivity, or sexual function scores did not vary between groups. Weak pelvic floor exercise strength was more common among the women with second-degree lacerations compared with women with an intact perineum (53% vs. 28%; P = .03) but did not differ between sutured (58%) and unsutured (47%) groups (P = not significant). Likewise, perineal body or genital hiatus measurements did not vary between groups (P = not significant). Conclusions: Women with sutured lacerations report increased analgesic use at the time of hospital discharge compared with women with intact perineums or unsutured lacerations. At 12 weeks postpartum, no differences were noted between groups regarding complaints of urinary or anal incontinence, sexual inactivity, or sexual function.

Misoprostol for intrauterine device insertion in nulliparous women: a randomized controlled trial

OBJECTIVE To examine the effects of preprocedure misoprostol on intrauterine device (IUD) placement in nulliparous women. STUDY DESIGN In this randomized controlled double-blind trial at the University of New Mexico reproductive health clinic, nulliparous women requesting an IUD were randomized to 400 mcg of buccal misoprostol or placebo 2-8 hours before insertion. Primary outcomes included pain on a 10-cm visual analog scale and womens perception of the value of delaying insertion for an effective medication. Provider ease of insertion and need for adjunctive insertion measures were also assessed, on a visual analog scale. Participants indicated maximum pain after IUD insertion, pain level they would tolerate to avoid delay in IUD insertion, and preference for IUD insertion without delay if an effective medication was available. RESULTS Of 85 women enrolled, 3 were ineligible; 42 were randomized to misoprostol and 40 to placebo. There were no differences between groups in worst insertion pain, (5.8 ± 2.0 vs 5.9 ± 2.0, P = .94), provider ease of insertion (2.2 ± 2.2 vs 2.5 ± 2.2; P = .54) or adjunctive measures (14% vs 25%; P = .27). The groups were willing to tolerate the same mean pain (4.9 ± 2.5 vs 5.7 ± 2.4, P = .18) to avoid waiting for medication. The majority of women (85%) preferred to wait for an effective medication. CONCLUSION Misoprostol for nulliparous women did not decrease pain or improve the ease of insertion of an IUD. Most women were willing to wait for a medication that decreases pain, indicating a need to pursue alternatives for pain control with IUD insertion.

Contribution of the second stage of labour to pelvic floor dysfunction: a prospective cohort comparison of nulliparous women.

Maternal expulsive efforts are thought to damage the pelvic floor. We aimed to compare pelvic floor function and anatomy between women who delivered vaginally (VB) versus those with caesarean delivery (CD) prior to the second stage of labour.

A Native American Community with a 7% Cesarean Delivery Rate: Does Case Mix, Ethnicity, or Labor Management Explain the Low Rate?

PURPOSE Cesarean delivery rates vary widely across populations. Studying communities with low rates of cesarean delivery may identify practices that can lower the cesarean rate. METHODS A population-based historical cohort study included all pregnant women (N = 1132) from 1992 through 1996 in a predominantly Native American region of northwestern New Mexico known to have a high prevalence of gestational diabetes and preeclampsia. The outcomes studied included delivery type (eg, cesarean, operative vaginal, spontaneous vaginal), indication for cesarean delivery, presence of obstetrical risk factors, and use of labor induction or augmentation. RESULTS The cesarean delivery rate of the study group (7.3%) was only 35% of the 1996 US rate of 20.7%. Among study participants, the relative risk of a primary cesarean delivery for dystocia was 0.22 (95% CI, 0.14, 0.35). Trial of labor after cesarean delivery was attempted by 93% of study participants compared with 42% of women nationwide in 1994. The cesarean delivery rates for women with diabetes in pregnancy (11.5% versus 35.4%) and preeclampsia (14.8% versus 37.4%) were significantly lower than nationwide rates. Case-mix analysis comparison with a standardized population and comparison of standard (ie, term, singleton, vertex) primiparous women demonstrate that the low rate of cesarean delivery was not because of a lower prevalence of risk factors. CONCLUSIONS The community’s low rate of cesarean delivery is primarily the result of a decreased use of cesarean delivery for labor dystocia and an almost universal acceptance of trial of labor after cesarean delivery. Cultural attitudes toward childbirth, design of the perinatal system, and genetic factors also may explain the low rate of cesarean delivery.