Oxford Handbook of Midwifery (32 page)

These rights are important, as adverse working conditions can affect the

health of the mother and fetus.

There is a significant association between preterm births, small for gestational age infants, maternal hypertension, pre-eclampsia, and working conditions.

Advise women who work during pregnancy that the following may limit their ability to stay at work for the full pregnancy, unless their employer can rearrange their workload or responsibilities:

All employees are entitled to 52 weeks maternity leave regardless of length of service or number of hours worked. Maternity leave is divided into 26 weeks ordinary maternity leave and 26 weeks additional maternity leave. Factsheets are available from Working Families (M www.
workingfamilies.org.uk).

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Sexuality during pregnancy and beyond

Sexuality is one of the most difficult areas of human experience to define, as it is complex, varied, and contradictory. Defined simply, it is a per- son’s capacity for sexual feelings, and childbirth is intrinsically linked with a woman’s sexuality and sexual health. The changes that occur during preg- nancy, childbirth, and the transition to motherhood are some of the most fundamental changes that a woman will encounter. Pregnancy is a normal life event that involves considerable adjustment by both the woman and her partner. A first pregnancy will bring the greatest changes. There are many contradictory and confusing aspects of pregnancy and sexuality, and it is a time surrounded by myths and misconceptions. It is the role of the midwife to dispel these myths and to provide sensitive support and infor- mation for the woman at all stages of pregnancy and childbirth.

Sexuality and pregnancy

How pregnancy affects sexuality will vary considerably from woman to woman. Women will be affected differently by physical and psychological changes that occur in pregnancy, as well as how they view their changing body image. Sexual desire may vary during pregnancy; it may decrease,

increase, or remain unaltered, depending upon the stage of pregnancy and

also upon other factors, which may include:

• Whether the pregnancy was planned or unplanned
  
• Whether the pregnancy was conceived naturally or with fertility treatment
  
• The response of others to the pregnancy
  
• Fears associated with pregnancy, e.g. harming the baby
  
• Stress, e.g. related to work, finances, etc.
  
• The woman’s health and how tired she feels
  
• Her relationship with her partner.
  

  Sexual intercourse is usually safe in pregnancy, provided both partners desire it and it does not cause discomfort. Sexual intercourse should be avoided in the relevant stage of pregnancy if there is:
  

• A history of recurrent miscarriages
  
• Vaginal bleeding
  
• Placenta praevia
  
• Premature dilation of the cervix
  
• Rupture of the membranes
  
• History of premature labour.
  

  Some women may find penetrative sex uncomfortable during pregnancy and this could be due to any of the following physical factors:
  

• Pelvic vaso-congestion: pelvic floor exercises may help relieve this.
  
• Vaginal congestion and reduced lubrication: lubricants may help.
  
• Retroverted uterus: particularly in the first few week of pregnancy.
  
• Subluxation of the symphysis pubis and sacro-iliac joints.
  
• Weight of the partner on a gravid uterus later in pregnancy: alternative positions may be adopted.
  
• Deep engagement of the fetal head.
  
• Infections of the genital area: candida,
  Trichomonas vaginalis
  , genital herpes, or warts.
  

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  Psychosocial factors may include tiredness, anxiety and fear, low self- esteem, poor body image, sexual guilt, interpersonal problems between the woman and her partner.
  

  Sexuality and labour
  

  Some of the procedures and examinations performed during labour involve the exposure of the genital area and penetrative vaginal examina- tion by either hand or a speculum. Many women find this very disturbing and difficult to cope with, not only because of the associated physical discomfort but also because of psychological feelings of vulnerability and powerlessness. This is especially relevant to women who have been sexu- ally abused. There is an increased need for awareness of these factors by midwives and doctors, who often perform these examinations in a ritual- istic manner and often without a sound rationale.
  

  Obstetric procedures, including artificial rupture of the membranes, episiotomies, instrumental deliveries, and caesarean sections can also have a profound effect on a woman’s sexuality. Many women find these procedures traumatic and they can have long-term consequences for sexual relationships.
  

  The experience of seeing their partner in childbirth can affect men’s
  

  sexuality. It can be a very powerful and overwhelming experience, which
  will bond the couple together, but it may also be a traumatic experience.
  

  The man may feel responsible for the pain and procedures his partner may be undergoing, or his reaction could be linked with feelings of inadequacy and powerlessness. In extreme cases this experience has been known to cause impotency.
  

  Midwives and obstetricians need to be aware of the implications of obstetric procedures and the traumatic effects it can have on the lives of couples who have been in their care.
  

  Sexuality postnatally
  

  Sexuality following childbirth is a much neglected area that is inadequately addressed by many midwives and health professionals. Sexual behaviour and sexual health of women following childbirth has been shown to be influenced by profound psychological, interpersonal, social, and physical factors.
  ¹
  Many women are anxious about their bodies following the birth of a child and this is linked to perineal pain, soreness, and a decreased sense of attractiveness. Sexual activity and enjoyment following childbirth is usually diminished for up to 1 year.
  

  Resuming sexual relations
  

  There is no set time when to resume sexual intercourse. It is more impor- tant that it is the right time for both of the partners. It is advisable to wait 3 weeks before having penetrative sex. It is important to avoid deliberately blowing air into the vagina during oral sex during pregnancy and in the weeks following birth, as this may cause an air embolism. Contraception needs consideration before resuming sexual intercourse, as the woman will ovulate prior to menstruating. Some women will experience dys- pareunia for a while following childbirth but if this does not resolve, they should be referred for medical advice.
  

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  Common causes of postnatal dyspareunia include:
  

• Decreased vaginal lubrication, either associated with breastfeeding or diminished sexual arousal
  
• Inflammation and infection
  
• Contracture and scaring of the perineum
  
• Sensitive hymenal or skin tags through malalignment of perineal repair.
  

  Breastfeeding and sexuality
  

  Women who breastfeed may find that they and their partners have a diminished sexual desire, while others may find it enhanced. The physi- ological and psychological experiences associated with breastfeeding may reduce sexual libido for the woman and also reduce vaginal lubrication. Tenderness of the breasts and leakage of milk may inhibit women from sexual activity while some men may find it off-putting.
  

  It is normal for some women to feel sexual arousal while breastfeeding, this is a response to the oxytocin increase during breastfeeding.
  ²
  Mothers will need reassurance as it may engender feelings of guilt and anxiety in the woman.
  

  Many women will not menstruate while exclusively breastfeeding.
  

  Menstruation returns when the number of night-feeds decline or when
  the baby begins to have solid foods and breastfeeding is less frequent.
  

  Ovulation will occur before menstruation returns and the mother needs to ensure adequate contraception if another pregnancy is to be avoided.
  

  Maternity care for lesbian mothers
  

  When considering sexuality in relation to childbirth, it is important to acknowledge that some mothers are choosing to have babies outside of a heterosexual relationship and some will have a female partner. Many lesbian women have negative healthcare experiences and therefore it is important that midwives provide support and information in a non- judgmental, sensitive woman-centred approach that takes into to consid- eration the individual mother’s needs. Specific considerations are:
  ³
  

• Disclosure of sexual orientation should be confidential and not recorded in the notes
  
• Other health professionals should not be informed without the woman’s expressed consent
  
• Provision of information should be appropriate to their needs
  
• The lesbian partners should be acknowledged as a couple and co-parents
  
• Creation of an atmosphere that acknowledges sexual diversity.
  
  1. De Judicibus MA, McCabe MP (2002). Psychological factors and the sexuality of pregnant and postpartum women.
     Journal of Sex Research
     39
     (2), 94–103.
     
  2. Convery KM (2009). Sexuality and breastfeeding: What do you know?
     American Journal of Maternal/Child Nursing
     34
     (4), 218–23.
     
  3. Royal College of Midwives (2000).
     Position Paper 22: Maternity Care for Lesbian Mothers
     . Reviewed 2005. London: RCM.
     

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  Dealing with disability during pregnancy and beyond
  

  Increasing numbers of women with disability are becoming users of mater- nity services, as they seek to live full and independent lives.
  ¹
  Often, simple measures can be taken by the midwife to enhance these women’s experi- ences of maternity services. The Disability Discrimination Act, related to ‘Access to goods, facilities and services’, came into force in December 1996, making it unlawful for service providers to discriminate against people with disabilities by:
  

• Offering a lower standard of services
  
• Offering less favourable terms
  
• Failing to make alterations to enable disabled access
  
• This includes all hospitals and healthcare facilities.
  

  Who are the disabled?
  

  The World Health Organization has defined disability as: ‘a restriction or inability to perform an activity in the manner or within the range consid- ered normal for a human being, mostly resulting from impairment’.
  ²
  

  However, the definition of disability varies widely between different social groups and cultures, as do the meanings which are attached to a
  

  person being labelled as disabled.
  ³
  In the UK it is very difficult to measure the number of disabled because, although local authorities must keep a record, disabled individuals are not required to register. Disability is also very subjective; not all people with impairments see themselves as disabled.
  

  The problem is one of society, not of disabled people themselves. Disability is the result of: