Constraints and / or determinants of return to sexual activity in the puerperium

Objective: to identify factors which constrain or determine the return to sexual activity in the puerperium. Method: exploratory and descriptive study undertaken in a university hospital in the South of Brazil. Fifteen women who had recently given birth, who received a consultation with the nurse in the period August – October 2011, took part in the study. Data was collected after the consultation had finished through semi-structured interviews, in which the women who had recently given birth were asked about the return to sexual activity and the feelings involved in this process. Results: the principal determinant/constraint for return to sexual activity in the post-natal period was the fear of a new pregnancy. Fear of feeling pain, permission from the health professional, shame of their own bodies and changes in libido emerged as constraining and/or determinant factors in the thematic analysis. Conclusion: it is considered fundamental for the issue of contraception to be addressed with the woman/couple during the pre-natal consultation, so that there may be opportunities for reflection and dialog prior to the critical time itself.


Introduction
The puerperium is understood as the period which begins straight after birth and ends when the local and general modifications determined by the gestation in the maternal organism return to normal conditions (1) .Some complex physiological and behavioral adaptations occur in women in this period, characterized by involutive phenomena, by the establishment of lactation, by the mother's psychological adaptation, and by the establishment of mother-child and family relationships.
The post-natal period is associated generally with a reduction in biological, psychological, marital and family well-being, often entailing a restructuring of the couple's family life as they seek to adapt to this new condition.The changes resulting from the pregnancy and the birth, present in the puerperium, are expressed as pain or abdominal discomfort in the perineal region, pain in the breasts, and muscle pain, which may also entail difficulties in self-care and in care of the baby (2) .
Changes in patterns of sexual activity and reduction in desire and sexual pleasure are observed after the birth of the baby, and may persist long after the end of conventional post-natal care.The post-natal period presents reduced or absent sexual activity, especially in relation to coitus, for the majority of women, whose reasons range from the tiredness inherent to pregnancy and to birth itself, to concern with maternal responsibilities, including the time period necessary for the genital apparatus to recover from the birth, particularly in the occurrence of an episiotomy or tear.At the same time, the low levels of estrogen tend to reduce vaginal lubrication, making coitus uncomfortable (3) .
Even having overcome the fears and recovered from the physical vulnerability, other obstacles to a satisfactory sexuality may remain, such as the excess of parental tasks, high anxiety, and worry.Husband and wife look less at each other and more at the baby, who passes to be the center of attention, leading one not to recognize the work or the value of the other, or even feel rejected (3) .There are also studies which report breastfeeding as an important factor in understanding sexual behavior during the puerperium, not only due to the hormonal factors involved, but because of the relationship which exists between breastfeeding and sleepless nights, which increase the fatigue.Breastfeeding's psychological implications are complex and can be important both for the man and the woman 4) .
In the first days after giving birth, the woman experiences a period of transition, in which she is vulnerable to any type of problem, and in which her emotions are highly sensitive, showing her need to feel cherished and respected.The woman needs to receive care in an integral way, as her body is passing through important changes, and she withdraws, so as to preserve and ensure her health and physical well-being, requiring a network of carers, made up by the family and health services (5) .
These listed factors are understood as constraints and/or determinants of the new mothers' return to sexual activity.The constraints refer to that which is dependent on certain conditions, which, from a Kantian perspective, function as a limitation of possibilities, while the determinants, in their turn, stipulate the causes of the occurrence of the phenomena, and can constitute a probable form of predicting the same (6) .
It is understood that knowledge of the constraints and/or determinants for return to sexual activity in the puerperium can be a helpful tool for the nurse during the nursing consultation, in the sense of helping with the instrumentalization of the new mothers for self-care and care of the baby in the most satisfactory way possible.
The nursing consultation is different from the medical consultation, in that it allows a closer relationship, characterized by its informality, relaxed character and flexibility (7) .
The nurse must take advantage of this space so as to recognize the needs and how they are expressed, for the resolution of the problems within her role, along with articulating other professionals and services through a clinical-educative and individual focus.For this, it is necessary to adopt measures which favor a practice of exchange and growth with the service user, taking on the role of facilitator (8)(9) .
There are few studies on this issue, which makes the topic relevant, causing the professional nurse to take a wider view of how obstetric care affects women's sexuality in the puerperal period.Considering the influence of the bodily transformations resulting from pregnancy and the post-natal period, it is important to understand and investigate the impact which these modifications can cause for the woman's sexual life during the puerperium, so as to promote a care directed to this population, implementing educative strategies even during the pre-natal consultations, as well as later, in the puerperium.Thus, so as to obtain support to perform this role better in the nursing consultation, and based on the Enderle CF, Kerber NPC, Lunardi VL, Nobre CMG, Mattos L, Rodrigues EF. confirmation of the knowledge gap involving this issue, concerning which the majority of studies are directed more at the physiology of the puerperal process than at the woman's needs, one has the following guiding question for the research: What conditions and/ or determines the return to sexual activity in the puerperium?On seeing the importance for this issue to be discussed and understood by the nurses who carry out the post-partum nursing consultation, and being aware of this delicate time in women's lives, this study was undertaken, with the aim of identifying the factors which condition and/or determine the return to sexual activity in the puerperium.

Methodology
This is a qualitative, exploratory and descriptive study, based on the premise that knowledge about the individuals is only possible through describing the human experience, as it is experienced and defined by its own authors (10) .The interviews were transcribed in full by the students of nursing.Afterwards, the nurse, together with researchers from the Living Women Research Group, sought to understand the data through reading and re-reading the material extracted.Later, the phase of exploration was developed, to as to identify recurring regularities in the data, which led to the categories of analysis (10) .For the categorization, the findings were preserved.As a form of identification, the new mothers were denominated using the letter 'E', followed by the order in which the interview was held.

Results
So as to give visibility to the women assisted in the postpartum nursing consultations at the HU, in the municipality of Rio Grande, their socio-demographic and obstetric profile will be shown first, followed by the constraining and/or determinant factors behind their return to sexual activity.

Characterization of the subjects
The age of the women who had recently given birth varied from 16 to 40 years; eight (8) were primiparas, 12 were single and 10 had normal births.Of those who had resumed sexual activity (7), only one was not breastfeeding; and of the new mothers who had not yet restarted sexual activity (8), two were not breastfeeding.
The principal method of contraception used was the low dose contraceptive pill, compatible with breastfeeding.The women mentioned waiting for the post-partum consultation to clarify their doubts and to be 'released' to resume sexual activity, that is, a constraining factor for resuming sexual activity was the health professional's approval regarding their gynecological condition.Among the 15 women interviewed, there was a predominance of vaginal birth (10), with no difference between types of birth and return to sexual activity.

The findings are presented in greater detail in
When the women who had resumed sexual activity were asked were asked about possible problems or discomfort, the issue of pain during coitus emerged from some of their accounts.

Discussion
The fear of a further pregnancy was determinant for the majority of the women interviewed not having resumed sexual activities, being referred to even by those who had resumed sexual activities, which may demonstrate insecurity and lack of confidence regarding the types of contraception used.Knowledge and information relative to this matter are not always adequate or clarifying, which can often lead to the woman or both members of the couple harboring feelings of doubt, insecurity and the fear of a close pregnancy.
The ideal is that for preference, clarification about control of fertility in the post-partum period should occur during the pre-natal consultations as the acceptance of the method, the degree of confidence in its effectiveness, the motivation for using it, and the correct guidance from the health professional are determinant factors for the success of the method chosen (10) .
To this end, the Ministry of Health (MS) recommends that the choice of the method of contraception must always be individualized and discussed starting right back during the pre-natal consultations.In providing guidance on the use of contraception in the post-partum period, one must take into consideration some questions such as: the time after birth, the breast-feeding pattern, the return or not of menstruation, and the possible effects of hormonal contraceptives on lactation and the breastfeeding baby (11) .
The fear of feeling pain also stands out, given that dyspareunia an important factor in resuming sexual activities in the post-partum period (12) .The weak motivation for sexual relations in the puerperium and their reduction in frequency have been explained by the fact that the women experience pain and discomfort during penetration (13)(14) .
When the women who had already restarted sexual activity were asked about the presence of some problem or discomfort, it emerged in the present study that pain on penetration was a common complaint.Pain, during sexual relations, influences female sexuality negatively, both in compromising sexual health and in the act itself, causing dissatisfaction in the women (15) .
In this regard, the type of birth -cesarean or vaginal -did not emerge as constraining or determinant for the women resuming sexual activities, it being observed that the interviewees represented similar percentages for this.This finding, despite converging in the literature with other studies (15)(16) may be a factor to be investigated further.
In one study on sexuality, which identified nursing diagnoses on sexual difficulties in the post-partum period, the "alteration in bodily function and structure" was the second factor related to this diagnosis, with 56.2%.The majority of clients who had recently had children reported problems related to sexuality, possibly due to the reduction in estrogen in the post-partum period, leading to alterations in the vaginal mucosa and entailing less lubrication and dyspareunia, which may occur even in the absence of episiorrhaphy (17) .
It may be observed that the women mention the post-partum consultation for more than simply clarifying doubts, but also as a moment in which they are "released" by the health professional to resume exercising sexual activities.Thus, in the light of the multiple biopsychosocial transformations which occur in the puerperal period, one should emphasize the need to work in a perspective which allows one to make integral and humanized care available to the women using the service (18) .
It is common for parents to have doubts regarding care of the mother and child in this period of puerperium, which emphasizes how important it is for the health professionals to provide them with support and assistance such that they may adapt to this new phase of life, with the arrival of another member of the family.The time spent in the consultation may be used to increase the women's knowledge about caring for themselves and their body, as the learning is processed through dialog, discussion and the insertion of the individual in the context which surrounds her (19) .
The health professional, by articulating technical and general knowledge about the puerperal period, provides the women and their families with understanding and clarification in relation to indispensable care in this phase, ensuring a better quality of life for the woman and the healthy development of the new-born (18) .Some consider that the libido is not the same as before the birth, besides the reduction in desire.
Regarding the woman's sexual satisfaction, the studies of the post-partum period show that this period is more difficult than the pre-pregnancy phase, in that only 20% time for reaching orgasm is estimated at seven weeks post-partum (20) .
The sexual response is controlled by the autonomous nervous system, and in a time of stress and anxiety, the relaxation necessary for success in sexual activity becomes impossible, resulting in unsatisfying experiences (19) .Sexuality cannot be seen in isolation or only in the moment, as it is part of the woman's whole life, being constructed during the different phases which the human being progresses through, from childhood through to the physical and emotional maturity of the adult; it is not limited to sexual relations or to reproduction, but rather is an integral part of the individual's life, in all ambits (6,(16)(17)(18)(19)(20)(21) .
The lack of sexual desire may compromise a relationship according to the extent to which the partner feels left to one side, or worse, suspects that he is no longer loved and that he has been exchanged for the new-born child, arousing a feeling of betrayal (22) .
Among the women who reported having resumed sexual relations after the birth, some asserted that this had brought the couple closer together, despite feeling ashamed of their bodies and feeling discomfort.Many factors contribute to this difficulty of the woman postpartum.The bodily changes which succeed each other over the pregnancy sometimes are associated with feelings of loss of self-esteem due to subjective perceptions of low physical attractiveness and inability to seduce (20) .
Frequently, there is also the idea of irreversibility relative to the body image held prior to the pregnancy.
The biological adjustment commonly occurs in the first six to eight weeks after the birth, but the return to the before-pregnancy body image rarely occurs during this period.Often this culminates in a negative development of body image, and of the conjugal relationship among the women (22) .
The woman may feel less attractive in the postpartum period and have evident low self-esteem, which negatively influences her sexuality, as in the postpartum period she has a perception of her body which is associated with the ideology of the biological body, admired and valued by the consumer society (21) .
Regarding sexual initiation, the results found allow one to ascertain that there is a predominance of the partner as initiator of sexual activity, a conclusion also verified by another study (in 54% of cases, it is the partner who takes the initiative; in 45%, both; in 1%, the woman) (23) .
In another study too, in the majority of cases it is the man who demonstrates greater initiative, before, during and after the gestational period.Further, generally speaking, what motivates the women to sexual activity is linked to the partner's needs, in the sense of marital obligation or a perception of the other's need for satisfaction.Although this may be verified throughout the process of transition to parenthood, it is particularly prominent in the first post-partum coital experience (20) .

Conclusion and final considerations
Because the fear of a new pregnancy in the puerperium itself is the principal determinant/ constraining for resuming sexual activities in the post-partum period, the authors consider that it is fundamental for this issue to be addressed with the woman/couple during the pre-natal consultations, so that there may be the opportunity for reflexion and dialog prior to the critical moment itself, so as to avoid Further research regarding the woman's sexuality in the puerperium must be undertaken so that it may be possible to understand in greater depth how women experience this period, so as to be able to intervene effectively when necessary and provide conditions such that the women feel free to report their experiences, with joint solutions for the possible difficulties found.
In detecting the women's fears, doubts and difficulties in family planning and sexuality, care for their own bodies in the post-partum period, and care for the new-born, expressed in the post-partum consultation, the nursing professional has a fundamental role, as she has sufficient knowledge to offer solutions to the needs the women present.In this way, monitoring during the puerperium by the nurse is shown to be very important in the face of the women's experiences.
Department of the Dr Miguel Riet Corrêa Jr University Hospital (HU) in the city of Rio Grande, in the state of Rio Grande do Sul.Part of the network of services which makes up the Unified Health System (SUS), this is a public hospital, where nursing consultations are carried out for low-risk new mothers, consultations for those at high risk being undertaken by doctors.The nursing consultation is held weekly, approximately 30 days after the birth, by one nurse and two students of nursing, the latter being responsible for data collection.Between August and October 2011, having agreed to participate in the research, 15 new mothers who had had their babies in the HU and who were receiving the postpartum nursing consultation took part in the study.In the period analyzed, 17 new mothers were attended, of whom two (2) refused to participate, possibly motivated by the presence of their partners in the consultation.The number was chosen based on the regularity found in the findings.The inclusion criteria were to be in a physical or psychological condition adequate to respond to the questions and to accept that the data would be included in the research; the consultation was undertaken in the usual way with the women who did not accept to participate in the study.Data was collected via individual interviews with the women who had recently given birth, in the outpatient center itself, after the consultation had finished, lasting about 30 minutes.A semi-structured script was used as the instrument, containing data for socio-demographic and obstetric characterization and open questions, directly asking about the return to sexual activity and the feelings involved in this process.
grouped by similarity and closeness in relation to the topics addressed.Based on the immersion in the data, those involved proceeded to the reading and the analysis of the possible determinant and/or constraining factors for return to sexual activity.The research project to which the study is linked was approved by the Federal University of Rio Grande's (FURG) Research Ethics Committee in the Area of Health (CEPAS), under Decision n. 67/2011.The women who participated, along with the legal guardians for those who were below 18 years of age, signed the terms of Free and Informed Consent, their anonymity being Constraints and/or determinants for return to sexual activityMoving on to the specific focus of this study, it was confirmed that the principal motive for the new mothers not yet to have restarted sexual activity was the fear of a new pregnancy, a fear which was also manifested by the women who already had started sexual activity.Of the seven women who had recently given birth who had already started sexual activity, five showed fear of a new pregnancy.Of the eight who had not started, seven referred to the same fear, which characterizes the fear of a pregnancy in the puerperal phase, as may be seen in some accounts.(...) fear of getting pregnant.I'm waiting for my husband to have the surgery (vasectomy) (E3); (...) because I still haven't finished the first course of the contraceptive pills (E6); (...) I'm scared of getting pregnant because I'm not on the Pill.(E9)Another determinant factor in this conduct is the fear of feeling pain due to the stitches placed in the vulva/perineum incision (episiorrhaphy) or in the surgical wound among those who received a cesarean.(...) I'm scared of the cesarean, because it seems like it might open up (E5); (...) I'm frightened of the pain in the stitches (episiorrhaphy).(E11) I thought I wasn't allowed.(E1); (...) I want to respect the quarantine period (E10); On medical advice, you should wait until the check-up consultation.(E13) of the women reach climax in their first post-partum sexual relation, this value increasing to 75% between the third and sixth month after the birth.The average Rev. Latino-Am.Enfermagem 2013 May-June;21(3):719-25.
or reduce problems.Factors such as the fear of pain in the stitches of the episiotomy or Cesarean lead the authors to reflect on the routine use of the episiotomy and the excessive number of Cesareans.Waiting for the post-partum nursing consultation as a constraint shows the confidence and security held in the professional knowledges.

Table 1 -
Socio-demographic and obstetric profile of the new mothers, in the nursing consultation.Outpatient Department, HU-FURG-Rio Grande, RS, Brazil

-views Age Marital status Nº of child-ren Days post-partum Type of birth Method contra-ception Breast-feed-ing
Enderle CF, Kerber NPC, Lunardi VL, Nobre CMG, Mattos L, Rodrigues EF.that the husband/partner showed interest and, after a dialog between the couple, sexual relations resumed.He sought me (...) and we talked (...) and that's how it happened.
Just pain and a 'certain' discomfort.(E7);(...) it doesn't hurt exactly, but there is discomfort, it felt like it was the first time, it was contracted, the desire was reduced (E2); (...) a little pain, it was different, I didn't feel much pleasure."(E12)Whenaskedaboutthefeelings produced by the return to sexual activity, the new mothers reported that having sex was something different, and that they felt ashamed of their own body.(...) I felt ashamed, but it was good (E4); (...) things are beginning to get back to normal).The couple needs time together (...) first the couple, then the children.(E8);(...) it was good, it brought us closer, it united us two"(E12;) I felt sad, because my body was still all wrong.(E15)Idon'tknow why.(E2);Worry about the baby, who wants tofeed all the time (E4); Difficult to say, because the woman's psychology is all shaken up, at least that's what happened with me (E8); It feels like it's wider 'down there' ( ...) (E12)Regarding the taking of the decision as to the period of return to sexual activity, the women affirmed www.eerp.usp.br/rlae