FIGURE 36-8 Cumulative proportion of breastfeeding women who ovulated during the first 70 weeks following delivery. (Data from Campbell OM, Gray RH: Characteristics and determinants of postpartum ovarian function in women in the United States. Am J Obstet Gynecol 169:5S, 1993.) sized, it does not invariably forestall it. Other findings in their study included the following: 1.
Resumption of ovulation was frequently marked by return of normal menstrual bleeding.
2.
Breastfeeding episodes lasting 15 minutes seven times daily delayed ovulation resumption.
3.
Ovulation can occur without bleeding.
4.
Bleeding can be anovulatory.
5.
The risk of pregnancy in breastfeeding women was approximately 4 percent per year.
For the breastfeeding woman, progestin-only contraceptives, such as progestin pills, depot medroxyprogesterone, or progestin implants, do not afect the quality or quantity of milk. Success with the progesterone-releasing vaginal ring has also been described (Carr, 2016). hese may be initiated any time during the puerperium. Estrogen-progestin contraceptives likely reduce the quantity of breast milk, but under the proper circumstances, they too can be used by breastfeeding women. hese hormonal methods are discussed in Chapter 38.
No evidence-based data guide resumption of coitus after delivery, and practices are individualized (Minig, 2009). After 2 weeks, coitus may be resumed based on desire and comort. Barrett and colleagues (2000) reported that almost 90 percent of 484 primiparous women resumed sexual activity by 6 months. And although 65 percent of these reported problems, only 15 percent discussed them with a health-care provider.
Intercourse too soon may be unpleasant, if not frankly painful, and this may be related to episiotomy incisions or severe lacerations. In a study of women without an episiotomy, only 0.4 percent of those with a first-or second-degree tear had dyspareunia (Ventolini, 2014). Conversely, in primiparas with an episiotomy, 67 percent had sexual dysfunction at 3 months, 31 percent at 6 months, and 15 percent at 12 months (Chayachinda, 2015). Dyspareunia was also common following cesarean delivery (McDonald, 2015).
Postpartum, the vulvovaginal epithelium is thin, and very little lubrication follows sexual stimulation. his stems from the hypoestrogenic state following delivery, which lasts until ovulation resumes. It may be particularly problematic in breastfeeding women who are hypoestrogenic for many months postpartum (Palmer, 2003). For treatment, small amounts of topical estrogen cream can be applied daily for several weeks to vulvar tissues. Additionally, vaginal lubricants may be used with coitus.
This same thinning of the vulvovaginal epithelium can lead to dysuria. Topical estrogen can again be ofered once cystitis is excl uded.
Taken together, major and minor maternal morbidity are surprisingly common in the months following childbirth. In a survey of 1249 British mothers followed for up to 18 months,
The Puerperium 663
Gin 87 percent of all women, at least one symptom was reported.
Data from Glazener CM, Abdalla M, Stroud P, et al:
Postnatal maternal morbidity: extent, causes, prevention and treatment. BJOG 102:282, 1995.