Coitus and late pregnancy, delivery, and the puerperium

COITUS

AND

LATE

PREGNANCY, PUERPERIUM” A Preliminary

WILLIAM (From

the Department

E.

School

AND

TXE

Report

M.D.,

PUGH,

of Obstetrics

DELIVERY,

~JOUISVILLE,

and Gynecology, Medicine)

Bs. Uniwrsity

of

Louisville

of

American textbooks of obstetrics are in general agreement the,t V ARIOUS coitus during the last two months of pregnancy is ill advised. Such complications as infection, premature rupture of the fetal membranes, premature delivery, and hemorrhage are described. The subject of coitus as related to late pregnancy, delivery, and the puerperium is absent from the American liierature, as listed in the Index Medicus, since 1916. The traditional advice given women by their physicians, to refrain from coitus during the final two months of their pregnancies, evidently stems from the existing outdated, foreign literature. Keller,’ in 1936, observed an 8 per cent puerperal morbidity in patients delivered spontaneously, who had not had intercourse 2 weeks or less prior to delivery. He reported a 10 per cent morbidity in patients delivered spontaneously who had had coitus 2 weeks or less prior to delivery. In operative vag inal deliveries the percentages were 31 and 36, respectively. Ruge2 found a 17 per cent puerperal morbidity in 82 women who had had intercourse during the last 3 days prior to delivery. He also reported 78.5 per cent of his patients as having coitus during the last 2 months before delivery. Schultze3 notes that Von Beuben was the first to formulate the theory that coitus in the last weeks of gestation predisposes to premature rupture of the membranes. Von Beuben found coitus occurring in 23 per cent of his patients 8 days or less prior to delivery. There was a 29 per cent incidence of premature rupture o-f the membranes in his series. So many facets of obstetrical practice have changed so radically since thclast contribution to the literature in 1937 that, we probably err in clinging to precepts put forth only up to that time. Here is an analysis of 100 unselected cases admitted to the obstetrical service of Louisville General Hospital between Aug. 6, 1951, and Sept. 7, 1951, intended t,o stimulate through new perspective, a re-evaluation of our ideas about coitus and late pregnancy. Material

and Methods

Of the 100 patients studied, 25 were primiparas and 75 were rnllltiparas; 63 were Negro and 37 were white. Eighty of the patients were married and 20 were unmarried. The latter group was composed of 11 single women, 6 separated, I divorced, and 2 widowed. All patients were studied objectively and subjectively. *Presented Louisville KY.,

at the ar?nual April 4, 1952.

meeting

of the Kentucky 333

Obstetrical

and

Gynecological

Society,

334 After the admission histor,v and physical clxamination, a sterile sped~~m examination of the vagina was done. T~v posterior vaginal fomix was cxpost?d and a smear made from it.s secretions. The tlried smears were then sent to t,li(k laboratory for staining, and examination for spermatozoa.. Next, the contents of the posterior vaginal fornix were aspirated with :I blunt-tipped, malleable cannula. Fluid thus obtained was placed in 0.5 ml. to 1.0 ml. of normal saline solution; mixed and heat.ed very gently ; and examined microscopically for evidence of motile spermatozoa. Patients were evaluated subjectively by their answers to this question, “ When was the last time you had intercourse before coming to the hospital’? ” which was asked routinely by t,he admitting resident and again by me 011 the first postpartum or second hospital da?. i1nswers were prompt, consistent, and in my opinion, as truthful as the patients’ memories permitted. Time of the last coitus prior to admission was usually reckoned by the patients in terms of days, weeks, or months. For this study all times have been recorded as days, on the basis of a 7 day week and a 2S ita? month. In text, figures, and tables, the time of last coitus prior to admission 1sexpressed in days as “time coitus. *’ Results Spermatozoa were demonstrated on two occasions in the wet preparations. The dry smears were uniformly negative (Table I). Since the objective search for spermatozoa in the vaginal fluid was 98 per cent negative, “time coitus” comesto the fore as the pertinent factor here reported. TABLE

--

---

I.

ASPIRATION OF POSTERIOR VAGINAL --.-~_~- ~-.-~~~-

PREPARATION

Soermatozoa go spermatozoa Total

WE P

2 98 100

FORNIX, 100 CASES -_____-DRY ..-.-__-~~. 0 100 100

Shortest average time coitus prior to admission (Fig. 1) was reported by white married multiparas; longest time average, by white unmarried primiparas. Except for Negro primiparas, in each corresponding group as to race and parity, as well as in the averages as to marital status, married women averaged the more recent time of intercourse. These results undoubtedly reflect the availability of the male to the ma,rried woman, as well as the social stigmas placed on the unwed gravida. In an analysis of age and parity groups with no reference to marital status (Fig. 2)) primiparas show the longer average number of days in both the 15 to 19 and 20 to 29 year age brackets; but do not appear at all in the 30 to 39 year category. A combined average of parities in each of the three age groups shows women at the height of t.heir childbearing yea.rs to he more incIined t,o abstinence, contrary to what one might expect,. For this study, the various complications of pregnancy, delivery, and the puerperium have been considered with no indication as to the degrees of severity, although they ranged from potential to real, and minor to major, difficulties. I have, however, appraised the complications as related or unrelated to coitus. Those deemed probably related to intercourse were puerperal morbidity, false labor, late antepartum bleeding, foul lochia and fever, premature rupture of the membranes, and premature labor. Primary uterine inertia, pre-eclampsia, essential hypertension, cholecystitis, breech presentation, occiput posterior position, and excessive weight gain were examples of complications considered unconnected with coitus, for obvious reasonsin each instance.

Volume Number

64

COITUS

2

IN

LATE

PREGNANCY

3:;.‘i

Puerperal morbidity and foul lochia and fever (Tables II and III) are Wviewed together because of their similarity except as to the degree of temperature elevation. One patient having puerperal morbidity and one having foul lochia and fever reported intercourse occurring the last time 7 days prior to admission. Coitus might have been the etiological factor in these cases, bllt many other factors would need be considered first. The 3 cases of morbidity in the puerperium had an average time coitus of 40 days. None of these were unusual instances of length of labor, duration of ruptured membranes prior to dt,livery, or method of delivery. The average total blood loss in the second atIf1 third stages of labor was 108 ml., and the average duration of the t,hird stirCr> of labor was slightly more than 4 minutes.

‘red -

Avaraae Matriad (80)

Uhiie M&ied

J“ig.

I.-Tinw

coitus

Fig.

delivery)

Fig. Fig.

Z.-Time 3.-Time

coitus coitus

in

;

C 010

Ihite

relation

to

marital

status.

race,

2. in relation in relation

to

age to

,

Unmarried

and

and

parity.

Fig.

3.

parity.

premature rupture

of

membranes

(time

prior

to

Neither were any of the 5 eases exhibiting foul lochia and fever unusua,l, except for one patient, the duration of whose labor was 22 hours and 30 minutes.

336 In this group of patients, t.he average total blood loss it1 the second and third stages was 170 ml., and the duration of the third stage of labor was 6 minutes. The average time of intercourse prior to admission was 49 days.

TABLE

-----~~

TOTAL

-

22 3 1 14 7

LENGTH LABOR

hrs. 30 hrs. 47 hr. 32 hrs. hrs. 12

ITT.

FOUL

~- - ~---.

--I----

LOCHIA

.w-n

FEVER.

DURATION

RlIPTllRED

-/~

MEMBRANES

min. min. min. min.

TYPE 1)ELIVERY

TIME COITUS

bpontaneous Spontaneous Spontaneous I,w forceps I,ow forceps .4vrrage

-I’ rniu. 1 hr. 7 hrs.

5 C:ASES

..___~

13 min.

Premature rupture of the fetal membranes (Fig. 3) occurred 19 t,imes in the 100 cases. Demonstration of amniot.ic fluid on sterile vaginal examination prior to the onset of labor was the governing factor in t,hese diagnoses. The 10 patients whose membranes ruptured 0 to 6 hours prior to the onset of labor show the longest average time of intercourse prior to admission. None of these patients developed amnionitis, foul lochia and fever, or puerperal morbidity. Two patients with times coitus 14 and 168 days did, however, have premature labor at 28 weeks’ gestat,ion which could not reasonably be attributed to late irit,ercourse. TAHLE .-

._:L.-;-.---ACE 18

*18 ix 28 37 *Spermatozoa

I\:.

FALSE GESTATIOPi (WEEKS)

RACE Negro

PARITY 0

38

White Negro White Negro White

0 vii iv v r

37 39 30 39 39

present

in wet

-___--

L,ABOR,

(i Cases ANTEPARTUM coMPT,IcAl'IoNs

None Antepartum, death of fetus Pre-eelampsia Cystitis, stress incontinence None Breech presentation Average

TIME COITUS

14n 1 28 4 42 28 41

preparation.

False labor was diagnosed 6 times (Table IV). The average time coitus for patients of this group was 41 days. Various incidental antepartum complications occurred, the most serious was the antepartum death of a fetus at 37 weeks’ gestation, recognized when the patient was admitted in false labor. The mother reported intercourse 24 hours prior to admission; and spermatozoa were found in the fluid aspirated from the posterior vaginal fornix. Fortyeight hours later the patient was admitted in normal labor. Autopsy failed to reveal the cause of fetal death, but the clinical impression was that an excessive11 short umbilical cord (20 cm.) was responsible. Table V is an analysis of the 6 cases in which late antepartum bleeding occurred. Bleeding begun 4 to 6 hours or more prior to the onset of labor was adjudged not incidental to the onset of labor. The average time coitus for all

COITUS

IN

LATE

PREGNANCY

3:3i

patients with late antepartum bleeding was 47 days. Vaginal spotting occurred 24 hours prior to the onset of labor in a patient at term who gave a history of intercourse 2 days before admission; spermatozoa were found in the wet preparation in this case: Aside from the spotting, this patient’s labor and delivery were uncomplicated. Another patient with a history of coitus 2 days prior to aclmission had vaginal spotting 18 to 24 hours before the onset of labor, and ruptured membranes 23 hours before delivery; but presented no complications of delivery or the puerperium. While there is at least a possibility that vaginal bleeding may be caused by cervical tra.nma due to coitus in late pregnancy. figures here do not. bear out this theory. --~~____-/ / /

AGE (YEARS) ___-. I7

I 1 P$RITY

RACE

I GESTATION j (WEEKS)

1

BLEEDING

/

OF

LABOR

ti-8

hrs.

iii

40 40

Spotting

24 hrs.

31

White White

z

40 40

Spotting Spotting

2-i hrs. 4-G bra.

36

Negro

i

3s

Spotting

Nemo

30

0

WlGte

SDottin~

/

OTHER COMPLICATIONS

~ COITUS

Sane

56

gain "7

None Fever and foul loohia

hrs.

18-24

Premature ture

of

2 112

rupmem-

2

branes

124

White

ii

31

M0derat.e

At

of

time

labor

Premature

labor

L’S

hverage *Spermatozoa t&Xilp

present in separation

premature

wet

TABLE AGE (YEARS)

R4(‘E

“t18 24

0 0

White

i

White

“’ 111

24

White

ii

22 28

White

iv

White

v

20

Negro

i

t4:

VI.

PREMATURE

T,ABOR,

9 CASES ._ ~~ --~~-~--~ TIME

GESTATION (WEEKSi

PARITY

~- White Negro

OTHER

---COMPLICATIONS

Antepartum death of fetus None None Pyelonephritis, antepartum death of fetus Premature separation of placenta Cystitis, stress incontinence Premature rupture of membranes Puerperal morbidity

37 36

Premature

~-

present fetal death TABLE -___

AN’lXPARTUM

VII.

COMPLICdTIONS

12

UNKELATED

DELIVERY 9

labor complicated

168 57

To

COITUS,

PIJERPEKAI, _--~~ -.--I

19

Css~s ‘TIME CUITIJM ~)lo.-“.

pregnancy in 9 of the 100 cases (Table VIj. was 57 days. Included again here is fetal death discussed under false labor; that of the I#-

Average time coitus in this classification

the case of antepartum

1 224

preparation.

INTRAPARTUN

12

Premature

in wet unknown.

__~--COITUS

of mem-

rupture

branes Average *Spermatozoa tCause of

4:

preparation. of placenta.

33x year-old white primipara in whose wet preparation spermatozoa were found. In the other antepartum death of a fet,us of 33 weeks’ gestation, autopsy was Neither maternal pyelonephritis not allowed and cause of death is unknown. nor the fact of a 28 days’ time coitus would seem to have an etiological connection with the death. Premat,ure rupture of the membranes occurred 3 and 4 days before delivery, in two patients having premature labor. Time coitus was 168 days and 14 days, respec.tively. The patient whose puerperal morbidity occurred subsequent to delivery at 28 weeks’ gestation reported last coitus 28 days prior to delivery. Again, in these data, there is no evidence to uphold us in our warnings against coitus in late pregnancy.

*Eleven

Fig. Fig.

cases

4.-Various 5.-Bkaluxtion

had

two

Fig.

4.

complications of entire

Fig.

G.-Last

complications Fig. related series.

coitus

14

to

days

5.

coitus.

or

less

prior

to

admission.

Table VII breaks down the complications, thought unrelated to coitus, occurring in 19 cases. Average time coitus for these patients was 81 days. The unusually high number of complications in each category charted in TabIe VII can be explained by the fact that certain complications, i.e., pre-eclamsia, anemia, and essential hypertension, remained present through the late antepartum, intrapartum, delivery, and puerperal phases of pregnancy, and are recorded under each phase. Analysis of Results Thirty-seven of the 100 patients that comprise this series exhibited 48 complications in the late antepartum and puerperal period (11 patients had 2 complications). All of the types of the 48 complications encountered could conceivably have been a result of coitus, but the average time coitus for these complications (Fig. 4) is sufficiently long that coitus seems improbable as the etiological factor. Also, there is no evidence to hold coitus responsible for the various complications in specific cases where recent coitus is cited. An evaluation of the entire series (Fig. 5) in reiation to the average times of last intercourse prior to admission, reveals that complications adjudged re-

zx:r624

COITUS

IN

LATE

PREGNANCY

339

lated to intercourse have an average time coitus of 50 days. This average time is shorter than that for the complications unrelated to coitus ; and shorter than that for the uncomplicated cases; and shorter than that for all the cases. However, these averages have no statistical significance. Twenty-seven patients of the 100 interviewed stated that their last coitus occurred 14 days or less prior to admission (Fig. 6) _ Twelve of this group had complications that were possibly related to coitus ; while 15 cases were uncomplicated, or without complications related to coitus. In the group of those having their la@ coitus 7 days or less prior to admission there were 10 cases in each category. And in that group reporting time coitus less than 7 days, there were 6 with complications possibly related to coitus ; and 3 cases uncomplicated, OI without complications related to coitus. Of the 6 cases with complications possibly related to coitus, 2 were false labor; 2 were late antepartum spotting, 18 to 24 hours prior to the onset of labor; two were premature labor-l case (previously discussed) of a 37 weeks’ gestation with antepartum death of t,he fetus: and one case at 30 weeks’ gestation with no other complications. Summary

and Conclusions

One hundred cases are surveyed as to the effects of coitus on late pregnancy, delivery, and the puerperium. For the purpose of appraisal, cases have been classified as those with complications related to coitus and those with complications unrelated; and uncomplicated cases. Conclusions must necessarily rest on further investigation. I hope that the results of this present study will stimulate that investigation, and will encourage us to de-emphasize abstinence during the final weeks of pregnancy, since time coitus appears to be of little significance, provided that the gravida is not uncomfortable during intercourse. Smith

I wish to thank Dr. Frank for their aid in collection

L. Fernandez, of the data.

Dr.

Meyer

J. Fleischman,

References 1. Koller, Theo: Schweiz. med. Wchnschr. 66: 48, 1936. 2. Ruge, Carl, Jr.: Munchen med. Wchnschr. 68: 1072, 3. Schultze, Guenther, 3. F.: Zentralbl. f. Gyngk. 61: 32:: EAST

CHESTNUT

STREET.

1921. 1038,

1937.

and

Dr.

Barton

‘r.