Disclaimer: This discussion and following summary contains mature content related to sex after childbirth, including physical, mental, and emotional considerations. Reader discretion is advised. You can watch or listen to our full conversation from the events page.

Why We're Here

Sex after childbirth is a topic shrouded in silence and stigma. However, the reality is that nearly half of postpartum individuals experience pelvic floor dysfunction, often leading to challenges in their sexual lives. In this candid conversation with Dr. Jessica Dufault, PT, we shed light on this under-discussed aspect of postpartum recovery. We explore the common issues faced, the physical and emotional factors involved, and the potential avenues of support. 

The statistics are startling: almost half of postpartum individuals grapple with pelvic floor dysfunction. And at 18 months postpartum, one in four people still experience pain during sex. While these challenges may be common, it shouldn't be considered your new normal. If you find yourself in this situation, you are not alone and support is available!

Topics Discussed

• What does it mean that pain, specifically with postpartum sex is common but shouldn't be considered your new normal?
• What symptoms are your clients coming in with?
• What happens at that initial 6 week check in?
• How do you support some of those physical concerns with sex, what does your approach look like? What are some things that people might be able to do to get to a better place?
• For people who don't have penetrative sex goals - how does your therapy differ or what does that look like?
• What does a pelvic floor assessment look like? For those of us that are maybe scared to go in for an initial appointment with you or someone like you, what should we expect?
• Can we hear one other client story? 
• Does perineal massage pre-labor help mitigate tears in pelvic floor tightening and postpartum? Because it sounds like maybe there's mixed messaging.
• What’s your approach for clients that feel “open/floppy” instead of tight & painful during sex?
• What other postpartum sexual health tips do you have?
• Resources

What does it mean that pain, specifically with postpartum sex is common but shouldn't be considered your new normal? 

Yeah, that's a great place to start. First I just want to say thank you, Jackie, for offering to host this and to facilitate this conversation. Particularly because it is under-discussed and it's really not talked about as a really common part of the postpartum experience.

Something that I've heard a lot, especially with the postpartum clients that I support is they thought what they were experiencing was just their new normal and that they had to just suffer in silence and maybe eventually this would get better. They saw maybe an Instagram post or perhaps they chatted with a friend who let them know that there was support. And then they found their way into my office. 

It really is not “normal”, but it is really common. We know based on research almost 1 in 4 of us will experience discomfort or pain with penetration still at almost 18 months postpartum. So imagine that you have an 18 month old baby and you're still having discomfort with penetrative sex. The thing about these stats is that they’re actually probably underreported. And we know that it's socially under-discussed. I just want you to know if this is you, you are definitely not alone, whether you've already experienced this or perhaps will experience some point in your life.

I want to talk about the physical aspects of why this may be occurring as well as touching on some of the mental and emotional barriers, because it all goes together when we talk about our postpartum sexual health. These things really can't be separated. 

What symptoms are your clients coming in with?

At a typical 6 week postpartum check-in, we walk away with a medical and cultural expectation that everything is healed and everyone should be returning to life as usual. Including penetrative sex. It's just not that easy. For most of us there are a lot of physical considerations to why this is occurring.

One of the most common things I see is scar tissue pain and restrictions.

This could be due to scar tissue restrictions at the perineum, in the vagina or general vulvar area, and also could be because of cesarean scar tissue restrictions. Oftentimes during vaginal birth there is disruption to the perineum - it could be minimal or severe (where it goes all the way to the anus). Sometimes there is vaginal tearing near or up into the clitoris. This is all muscle, so really that can happen anywhere along that line. Whether or not you've had stitches to repair tearing we want to address that scar tissue.

A cesarean incision is in close relation to your pelvic floor muscle, and can still have an impact.

Note: Grade 1 (G1) tears are considered physiologically normal part of the birth process, oftentimes doesn't need stitching and essentially can heal well quickly. G2 starts to get into the muscle. G3 means it might reach that external anal sphincter and a grade 4 is all the way through. Jessica walks through these on a model in the session, there is a reference from The Mayo Clinic here.   

People who are postpartum often assume that the pelvic floor is just kind of stretched and weak. But my experience is that oftentimes postpartum, there's actually reflexive tightening or tension that happens in the pelvic floor. We just had a baby pass through. There may be scar tissue. So the pelvic floor can tend to tighten down in response, leaving less space for penetration. 

 Other physical restrictions: 

• Pressure or heaviness, or a feeling that “something's falling” as organs shift their position and can impede in vaginal space. 
• Dryness. Early postpartum there is a significant drop in our estrogen. Estrogen brings blood flow to create natural lubrication. There’s a double whammy for those who are breastfeeding because of prolactin that's required. The vagina & vulva are highly dependent on this perfect balance of hormones; and early postpartum there are a lot of hormone fluctuations which can affect the tissue creating Sahara-level dryness. 
• Feeling “touched out.” Sexual health may be the last thing on your mind. 

 Mental & Emotional barriers 

• Postpartum bodies look and feel different! Body image can definitely impact your postpartum sexual health. 
• Performance anxiety; concerns about how things will feel or be different for the partner if you're someone who's participating in penetrative sex
• Birth trauma, postpartum depression, postpartum anxiety are oftentimes a huge piece to the puzzle about changes in sexual health as well. 
• Priorities are shifted elsewhere. There's a shift in dynamics of the relationship, or what you have time, energy and attention for. Sleep deprivation and mental health may leave you feeling like there is nothing left in the tank for sex.

You can have a different experience with different kids as well! Each postpartum experience can be completely different than the previous one. Just like all births and all outcomes can be different and then just how you're feeling postpartum.

What happens at that initial 6 week check in?

Most health care providers are looking at 3 important things: 

1. Check out perineal or cesarean scar tissue to ensure it's healing well.
2. Screen on mental & emotional health 
3. Talk about birth control discussion. Note: It is possible to become pregnant shortly after having a baby, even if you are exclusively breastfeeding. If that is not your goal, talk with your doctor about the best contraception options for you.

Medically, at this point in the postpartum journey, you may get a message of “Woohoo, you made it to 6 weeks. You've, you've healed, you're, you're ready to go;” when in reality, that's just the beginning of the postpartum recovery. Really we're looking at a full fourth trimester of healing, and sometimes even 6 to 12 months for that full healing. I want to set the expectation that it’s great if your scar tissue is healed, the vagina looks fine, the belly looks fine. But that's not the end of the story.

It is a long process! Be patient with yourself.

How do you support some of those physical concerns with sex, what does your approach look like? What are some things that people might be able to do to get to a better place?

I've had permission from a couple of clients to share their detailed experiences. First, I want to say many, many, many people do not feel physically, mentally, emotionally ready to return to sex at 6 weeks. My client Olivia, for example, had a vaginal birth with a grade 2 perineal tear. She had stitches and at her 6 week check-in the doctor said “everything looks good. You can return to everything you want to return to, including sex.” She was excited about that, so was her (male) partner and they did attempt to return to penetrative sex. It didn't go so well. Over the course of many trials of penetrative sex, they needed to stop due to her pain and discomfort. 

When we did her assessment she had pretty significant scar tissue & pelvic floor tension that was restricting access.

• We incorporated scar tissue massage. There's lots of ways that can happen: You can do this yourself, have a partner help you, or have your physical therapist assist. A pelvic wand tool is often used to reach that area efficiently and without straining your body. This same tool can massage & release tension in the muscles of the pelvic floor.
• Also something that's pretty critical to almost every postpartum person I support is breath work. Breathe, breathe, breathe. 
• Your pelvic floor is very intricate and connected to your breathing muscle. These 2 things have a relationship when you inhale & exhale. We can really tap into the power of your breathing muscle to help create a healthier environment for the pelvic floor.
• Sometimes, we may want to use a medical device, called a dilator to help attain pain free penetration. Usually these start small and they build in size. We really want to start with the size where it feels like “This is safe. This is pain free. I'm having gentle penetration with and I'm stretching that scar tissue and I'm practicing that breath work but without that fear of it being painful” because as soon as we experience pain with penetration, the body has this protective response. If penetrative sex is important for you to get back to, we want to build that size up to whatever your goal is for that penetrative size.

For people who don't have penetrative sex goals - how does your therapy differ or what does that look like?

Yeah. Love this question because I think that in general your postpartum pelvic health is really important beyond penetrating sex. What that means is the state and the health of your pelvic floor is really dependent on that scar tissue and those muscles being really extensible and mobile and flexible. So even without penetrative goals, we want to work on that because then your pelvic floor will be stronger. Your core will better support you. And that's an effort to help things like how you move your bowels and if you lose urine when you jump or cough or laugh or sneeze -  scar tissue and pelvic floor therapy would really be a priority for all of those things, not just penetrative sex. So I'm a little biased, but I think everybody should have at least one postpartum pelvic physical therapy assessment just to address those things.

What does a pelvic floor assessment look like? For those of us that are maybe scared to go in for an initial appointment with you or someone like you, what should we expect?

It is really common for my clients to be nervous when they're coming into their session because they really don't know what to expect. I focus on lot of information sharing and a lot of informed consent. We talk about your symptoms and I work to understand your goals. I do an orthopedic screen & a core muscle screen.

If we do a pelvic exam, (often why the majority of my clients are in my space):

• In a private room, we talk. Then I explain about the pelvic exam and what it looks like - no speculum, no stirrups, just a single finger exam vaginally. 
• Exam takes place lying comfortably on my treatment table. I talk through everything step by step, what I'm doing, what I'm feeling. 

For anybody who says, “I'm just really not feeling up for an (internal) pelvic exam today,” we can do an external assessment to feel the nature of what the pelvic floor is doing and where it may need some support. 

Can we hear one other client story? 

This is a client again who gave permission for me to share this. She came to me at 6 months postpartum and she had experienced some birth trauma, including a grade 4 perineal tear and she was terrified to even attempt penetration at all. Her and her partner had talked through this; she just didn't even want to go there and she consulted with her OB/GYN because she had felt there were some pretty severe restrictions and discomfort still. The OB/GYN suggested a revision surgery. My client did not want to do this because she had been through birth trauma, she was still not recovered and feeling very uncomfortable. She did schedule that revision surgery, but it was a couple months out and she wanted to try pelvic floor physical therapy in the meantime. From my exam, I assessed the restrictions on the severe end of things - both scar tissue and the pelvic floor. I was really honest with her and said, you know, I'm not sure that we can 100% meet your goals, but I'm certainly willing to try. We started a plan of care together, not that much different than Olivia's:

• Scar tissue work that she was doing herself at home with help from her partner. 
• A lot of breath work and stretching into certain postures that we know help release some of the scar tissue and pelvic muscle tension.
• With her case in particular, I really felt she would benefit from a trauma-informed sexual health therapist to do some sort of mind-body work, or somatic work to help her process through that trauma, really in an effort for her to meet her physical goals. I thought that was a pretty vital piece.

This client went to her OB/GYN for another consultation prior to surgery, and the OBGYN said, “wow, this actually looks a lot better, how are things feeling?” While she hadn’t quite yet met all of her goals, she had progressed enough to know that she was not going to do the revision surgery.

Does perineal massage pre-labor help mitigate tears in pelvic floor tightening and postpartum? Because it sounds like maybe there's mixed messaging.

There is definitely mixed messaging - the research is pretty inconclusive. So here's how I feel about perineal massage: I don't necessarily believe that we're actually stretching the perineum. But I still think there's some value to it. As you're doing your prenatal prep, it's also a space for you to get that mind-body connection and practice your breath work, that connection of your breath work to your pelvic floor so that even amidst the discomfort you're learning to stay present, to really walk into that breath for not only pain management but also to keep the pelvic floor softened and released. I think there's some value to having that mind-body connection in place ahead of time so that you can draw on it when you need it during the birth.

After my second (vaginal) delivery I didn't have a lot of tightness. I had sort of the opposite - like a big open floppy cave situation going on - this was an emotional body image challenge for me. What would you do with a client coming to you in that case? 

I appreciate you being so willing and open to share your experience and I think that's really important because the more we talk about this and the more we normalize the conversation, the better for everybody who's eventually going to be postpartum, right? The answer is it might not be all that different. We're still going to want to address any scar tissue restrictions. We're still going to tune into the power of breath and how that connects to your pelvic floor. But in this scenario, we may not be trying to loosen tense muscles. We may be trying to then get the muscles to actually be able to contract. 

 I'll briefly talk about the K word (Kegels). I actually don't love kegels. In this situation where we're trying to work strength, we will want to tap into all parts of this system. There's never a situation in which the body needs to only squeeze one part of the system. Rather, we are going to use really specific techniques and strategies to make sure we're incorporating all pieces to the puzzle. In that situation we would work a ton on strength training, in a very specific way that is not just focusing on Kegels.

What other postpartum sexual health tips do you have?

• Communication with your partner about this is important. Oftentimes people are really hesitant to let their partners know that things are uncomfortable or that they would prefer to forego penetrative sex at this moment. That communication and conversation is really important. 
• I can't emphasize enough the importance of trauma informed therapy, whether that’s sex therapy or somatics. This could be on your own or with your partner as well.
• I love a local resource we have here in Madison, Wisconsin called A Women's Touch  - it's basically healthy sexuality resources for everyone. 
• You can prepare for postpartum during pregnancy! Both to keep your body moving and feel healthy, but also to help prepare for birth so that we're actually helping reduce pelvic risks for all the things we see postpartum. 
• Pelvic PTs typically won’t do a pelvic exam until 6 weeks postpartum or until when you’re cleared by your midwife or Ob/GYN. But, they are able to provide support and education, answer questions, ease their fears or concerns (via telehealth if desired) before that 6 week postpartum. 
• It’s never too late postpartum to get started with an evaluation! Even if you are several months (or years) after childbirth, you can still see a Pelvic Floor PT and put a plan together. 

I want everybody to know that returning to a satisfying sex life is absolutely possible.

But it's gonna take some time, some patience, and perhaps some work to get there and by work I just mean perhaps seeing a pelvic floor physical therapist and doing some of that self-care and and homework. And one thing that doesn't get talked about enough is that sometimes - especially early postpartum -  desires and things that bring pleasure may change a little bit. And that's okay. Just explore that a little further and discover exactly what that means for you.

Resources

• Free community support from Dr. Jessica Dufault on Facebook 
• Postpartum Sexual Wellness brochure from A Woman's Touch
• The Gottman Institute shares that while two-thirds of relationships are rough post-baby, there are ways for passion and parenting to co-exist
• Virtual postpartum recovery program from Day 1 - Week 12 from That Pelvic Lady.
• Finding a trauma informed sexual health therapist: Ask your Pelvic Floor PT, talk to your primary care doctor, or check with your insurance
• Get your pelvic wand, dilator, or other products 
• Finding a Pelvic Floor PT 
  • Mindful Motion Physical Therapy for those in and around Madison, WI 
  • Around the US - if you don't want to google and call around for availability, the Popins Community Connection service has you covered.

About the Expert

Jessica Dufault, PT, DPT of Mindful Motion Physical Therapy is a Pelvic Floor Physical Therapist, Birth Coach and mom. She loves the complexity and challenge of understanding human bodies, especially female ones. Filling the gap between the support women need and what they actually get is what gets Jessica going. You can find her on Instagram @that_pelvic_lady.