FUNCTION , PRACTICES AND SEXUAL POSITIONS OF PREGNANT WOMEN

Objective: to characterize the function, practices and sexual positions of pregnant women. Method: this is an integrative review performed in April 2017, in the MEDLINE, Lilacs, IBECS, CINAHL, BDENF and SciELO virtual libraries. There were 1,439 articles identified. After the application of the filters, inclusion, and exclusion criteria, 11 articles composed the sample. Results: the results showed four thematic categories << Sexual practices during pregnancy >>; << Sexual positions during pregnancy >>; << Sexual Function domains >> and << Related Aspects of Sexual Function >>. Conclusion: during pregnancy, there is a reduction in the frequency and/or restriction of sexual practices and positions, besides to changes in all domains and related aspects of sexual function. Sexual practices and positions have not been evaluated and/or specified by most primary studies. Descriptors: Women's health; Pregnancy; Sexuality; Sexual behavior; Review. RESUMO Objetivo: caracterizar função, práticas e posições sexuais de mulheres grávidas. Método: revisão integrativa realizada em abril de 2017, nas bases de dados MEDLINE, Lilacs, IBECS, CINAHL, BDENF e biblioteca virtual SciELO. Identificaram-se 1.439 artigos, após aplicação dos filtros, critérios de inclusão e exclusão, 11 artigos compuseram amostra. Resultados: os resultados evidenciaram quatro categorias temáticas << Práticas sexuais na gestação >>; << Posições sexuais na gestação >>; << Domínios da função sexual >> e << Aspectos correlatos da função sexual >>. Conclusão: durante a gestação ocorre redução na frequência e/ou restrição de realização de práticas e posições sexuais, além de alterações em todos os domínios e aspectos correlatos da função sexual. Práticas e posições sexuais não foram avaliadas e/ou especificadas pela maioria dos estudos primários. Descritores: Atenção à Saúde; Saúde da Mulher; Gravidez; Sexualidade; Comportamento Sexual; Revisão. RESUMEN Objetivo: caracterizar función, prácticas y posiciones sexuales de mujeres embarazadas. Método: revisión integradora realizada en abril de 2017, en las bases de datos MEDLINE, Lilacs, IBECS, CINAHL, BDENF y biblioteca virtual SciELO. Se identificaron 1.439 artículos, después de la aplicación de los filtros, criterios de inclusión y exclusión, 11 artículos compusieron la muestra. Resultados: los resultados mostraron cuatro categorías temáticas << Prácticas sexuales en el embarazo >>; << Posiciones sexuales en el embarazo >>; << Dominios de la función sexual >> y << Aspectos correlatos de la función sexual >>. Conclusión: durante la gestación ocurre reducción en la frecuencia y o restricción de realización de prácticas y posiciones sexuales, además de alteraciones en todos los dominios y aspectos correlatos de la función sexual. Prácticas y posiciones sexuales no fueron evaluadas y o especificadas por la mayoría de los estudios primarios. Descriptores: Atención a la Salud; Salud de la mujer; Embarazo; Sexualidad; Comportamiento sexual; Revisión. Master degree, Master's Program in Nursing – Level Academic Master's Degree, Regional University of Cariri/URCA. Crato (CE), Brazil. E-mails: emanuelly.v.p@gmail.com ORCID iD: https://orcid.org/0000-0003-1457-6281; jam.ex@hotmail.com ORCID iD: https://orcid.org/0000-0003-1903-3446; juscinaidehenrique@hotmail.com ORCID iD: https://orcid.org/0000-0002-5547-6247; Ph.D., Master's Program in Nursing – Level Academic Master's Degree, Regional University of Cariri/URCA. Crato (CE), Brasil. E-mails: evanira@bol.com.br ORCID iD: https://orcid.org/0000-0001-9377-7430; glaubertoce@hotmail.com ORCID iD: https://orcid.org/0000-00015488-7071; Ph.D., Postgraduate Program in Sustainable Regional Development (PRODER) Academic Master's Degree, Federal University of Cariri (UFCA), Juazeiro do Norte, (CE), Brazil. E-mail: paulo.firmino@ufca.edu.br ORCID iD: https://orcid.org/0000-0002-3308-2650 INTEGRATIVE REVIEW ARTICLE Pereira EV, Belém JM, Alves MJH et al. Function, practices and sexual positions... English/Portuguese J Nurs UFPE on line., Recife, 12(3):772-80, Mar., 2018 773 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i3a231225p772-780-2018 Sexual function encompasses the desire, excitement, orgasm and related aspects (comfort, pain, lubrication, pleasure, interest, satisfaction, initiative and sexual disposition) that result from a complex interaction between biological, sociocultural and psychological factors. While sexual practices can be a means to obtain pleasure and/or sexual satisfaction, regardless of type (vaginal, oral, anal and masturbation) and embodiments; sexual positions are the way in which the body remains during the sexual act. The domains of sexual function and related aspects may vary by gestational trimester due to hormonal, physical, psychological, experiences, meanings, roles and sociocultural contexts, as well as interfere with the sexual practices and positions adopted. As a result of these aspects, it is observed that scientific publications included in review on the subject tend to emphasize pathological aspects to the detriment of sexual function. In a previous survey on female sexual function in gestation, only one review article was identified including publications indexed in a database and examined in a specific way sexual function in pregnancy and puerperium, relating it to the way of delivery and interventions performed during parturition as factors for sexual dysfunction. In view of the above, investigations related to the sexual practices and positions performed during pregnancy as constitutive elements of sexuality need further clarification regarding the implications of sexual function. ● To characterize the function, practices, and sexual positions of pregnant women. This article was extracted from the dissertation << Sexual function during pregnancy: analysis of sexual practices and performance >>. Postgraduate Program in Nursing at the Regional University of Cariri (URCA), Crato, (CE), Brazil, 2017. It is an integrative review of the literature that fulfilled the steps: identification of the guiding question; establishment of criteria (inclusion and exclusion); categorization; evaluation of included studies; interpretation of results; and submission of review. The search was done in a paired form in April 2017, in the databases MEDLINE, Latin American Literature in Health Sciences (LILACS), Spanish Bibliographic Index of Health Sciences (IBECS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Nursing Database (BDENF) and Virtual Library Scientific Electronic Library Online (SciELO), using advanced search method and categorizing title, abstract and subject. The subject was searched for by Medical Subject Heading (MeSH), National Library of Medicine's National Institutes of Health (PubMed). The Population, Variables, and Outcomes (PVO) strategy (Table 1) was used to choose the MeSH descriptors to answer the question: How are the practices, positions and sexual function of pregnant women characterized by the literature as dimensions of sexuality? Table 1. MeSH descriptors for the components of the guiding question. Crato (CE), Brazil, 2017. Strategy Items Components Subject Descriptors Population Pregnant women Pregnancy Variables Practices, positions, and sexual function Sexual Behavior Outcomes Sexuality Sexuality As a search strategy, a crossing in each database and the data library with Boolean operators to were used associate the descriptors: Pregnancy AND Sexual behavior AND Sexuality. The search was conducted through the journal portal of the Coordination of Improvement of Higher Education Personnel (CAPES), with 855 in MEDLINE, 442 in CINAHL, 60 in LILACS, 56 in SciELO, 16 in IBECS, 10 in BDENF, totaling 1,439 references, submitted to a four-stage filtering process: full text available; language (Portuguese, English and Spanish); type of document (article) and year of publication (January 2005 to April 2017). After the filters were applied, 303 references were left. Then, the titles and abstracts were read, exclusion of duplicates and analysis was performed according to inclusion criteria: original research on the subject; and exclusion criteria: structured in the format of editorials, comments, brief communications, review or reflection articles, documentaries, essays, abstracts, reviews, theses, dissertations, monographs and experience reports; not be available in full text for download or do not answer the study question. We selected 11 articles that composed the final sample. OBJECTIVE INTRODUCTION

Sexual function encompasses the desire, excitement, orgasm and related aspects (comfort, pain, lubrication, pleasure, interest, satisfaction, initiative and sexual disposition) that result from a complex interaction between biological, sociocultural and psychological factors. 1 While sexual practices can be a means to obtain pleasure and/or sexual satisfaction, regardless of type (vaginal, oral, anal and masturbation) and embodiments; sexual positions are the way in which the body remains during the sexual act. 2 The domains of sexual function and related aspects may vary by gestational trimester due to hormonal, physical, psychological, experiences, meanings, roles and sociocultural contexts 3 , as well as interfere with the sexual practices and positions adopted. 4 a result of these aspects, it is observed that scientific publications included in review 5 on the subject tend to emphasize pathological aspects to the detriment of sexual function.In a previous survey on female sexual function in gestation, only one review article 6 was identified including publications indexed in a database and examined in a specific way sexual function in pregnancy and puerperium, relating it to the way of delivery and interventions performed during parturition as factors for sexual dysfunction.
In view of the above, investigations related to the sexual practices and positions performed during pregnancy as constitutive elements of sexuality need further clarification regarding the implications of sexual function.
• To characterize the function, practices, and sexual positions of pregnant women.This article was extracted from the dissertation << Sexual function during pregnancy: analysis of sexual practices and performance >>.Postgraduate Program in Nursing at the Regional University of Cariri (URCA), Crato, (CE), Brazil, 2017.
It is an integrative review of the literature that fulfilled the steps: identification of the guiding question; establishment of criteria (inclusion and exclusion); categorization; evaluation of included studies; interpretation of results; and submission of review. 7e search was done in a paired form in April 2017, in the databases MEDLINE, Latin American Literature in Health Sciences (LILACS), Spanish Bibliographic Index of Health Sciences (IBECS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Nursing Database (BDENF) and Virtual Library Scientific Electronic Library Online (SciELO), using advanced search method and categorizing title, abstract and subject.The subject was searched for by Medical Subject Heading (MeSH), National Library of Medicine's National Institutes of Health (PubMed).
The Population, Variables, and Outcomes (PVO) strategy (Table 1) was used to choose the MeSH descriptors to answer the question: How are the practices, positions and sexual function of pregnant women characterized by the literature as dimensions of sexuality?After the filters were applied, 303 references were left.Then, the titles and abstracts were read, exclusion of duplicates and analysis was performed according to inclusion criteria: original research on the subject; and exclusion criteria: structured in the format of editorials, comments, brief communications, review or reflection articles, documentaries, essays, abstracts, reviews, theses, dissertations, monographs and experience reports; not be available in full text for download or do not answer the study question.We selected 11 articles that composed the final sample.A flowchart of the Preferred Reporting Items for Systematic Review and Meta-Analyzes (PRISMA) 8 was used to describe information at each step of the search and selection of studies, as can be seen in Figure 1: The levels of evidence (LE) of the studies that compose the sample were categorized into six levels: Level 1: evidence resulting from the meta-analysis of multiple randomized controlled clinical studies; Level 2: Evidence obtained from individual studies with experimental design; Level 3: evidence from quasi-experimental studies; Level 4: Evidence from descriptive studies (nonexperimental) or qualitative approach; Level 5: evidence from case or experience reports; Level 6: evidence based on expert opinions. 9

METHOD
The data were organized into four thematic categories, classified and grouped by content similarity according to data extracted from the primary studies.Data analysis was performed using the data reduction method. 10t involved classification and division techniques in subgroups of primary sources according to the approach and methodological aspects.After coding procedures, extracted information was analyzed according to similarities and divergences; reduced and compiled in electronic spreadsheets, submitted to validation via double typing to eliminate possible errors and guarantee reliability.
This approach allowed organizing data in a logical structure, to simplify, to summarize, to abstract and to compare systematically information contained in the primary sources on specific questions, variables or characteristics of sample. 10e characterization of the studies is presented in synthesis-table and the results in thematic categories according to the objective of the study and they were discussed according to the pertinent literature.
The data contained in Table 2 summarize the main information of the articles analyzed.The studies aimed to evaluate 14,15,20 or compare 17 sexual function and the factors that affect it; analyze 13 , describe 19 or determine 12 sexuality and its influence on pregnancy; investigate 16 sexuality and sexual function; to know 11 sexual activities; evaluate behavior 17 or sexual activities, attitudes, and behaviors during pregnancy. 21garding the data collection instruments, there was a predominance of the Female Sexual Function Index (FSFI) [14][15][16]20 , besides to a Likert questionnaire 12 , Sexuality Questionnaire in Gestation (QSGx) 13,18,21 , Sexual Quotient -Female Version (QS-F) 17 and a validated instrument, not specified 11 . Tw studies used a qualitative approach; the first one 19 used a theoretical-methodological reference of Symbolic Interactionism and the Grounded Theory and semi-structured interview; the second study 13 , although described as qualitative, it used a questionnaire and analyzed the data by descriptive statistics.The pregnant women included in the two qualitative studies varied from 11 19 to 25 13 , while in the quantitative studies, the sample ranged from 40 20 to 2.117 14 , with an approximate average of 591 participants.Regarding the type of sampling, eight studies 11-13,15,16,19-21 reported stratification by quarter. Amng these, two 10,11 performed proportionally and the other [13][14][15][19][20][21] for convenience, which resulted in greater number of participants in the second 14,15,21 , third 13,19 and first 20 gestational trimesters.Three studies 15,17,18 selected women with gestational ages restricted to the first 16 , second or third 17 trimesters.

English
Due to the nature of the topic presented, as well as to the methodological design of the included studies, it was observed that the articles analyzed were predominantly classified as Level 4 of scientific evidence. 11,13- 17,19

 Category 1 -Sexual practices of pregnant women
Vaginal sex was described in three studies 13,18,21 , oral, anal sex and masturbation in one study 21 .In masturbation, there was interruption in performing anal and partially vaginal sex or only performing preliminary sexual practices in the form of caresses. 19reduction in the frequency of sexual practices during gestation was observed. 11- 13,15,16,18-21Although two studies 14,17 did not evaluate this aspect, some studies 11,13,15,20,21 verified variations according to the gestational quarter which occurred progressively 11,13,20 or non-progressive. 12,15,21egardless of this classification, the findings indicated that the third trimester was less favorable for performing sexual practices 11,13,15,20 although two studies pointed out the first 21 and second quarters. 12ere was a reduction in vaginal sex related to the progression of pregnancy 18,21 , advanced maternal age, nulliparity, third quarter, culture, inadequate knowledge, and anxiety. 21In one study, there was an increase in frequency of vaginal sex and greater willingness of the partner to sexual activity in all quarters, and pregnancy was not an impediment to maintaining them. 13ong the possible causes associated with the reduction in the frequency of sexual practices, there were: employment 15 , discomfort 13,17,19 related to difficulty accepting and lack of relaxation for penetration 17 , dispaurenia 13,17,20 , pregnancy awareness 16 , difficulties of concentration during sexual act and attunement with partner 17 , indisposition for sexual act 13 , sexual abstention in the first, 13,15,19 seconds 13,19 and with greater amplitude in the third 13,15,19 quarters; related to the corporal changes 13,19 and cultural conceptions of the partner 13 ; fear of injuring the fetus 13,21 , losing a partner during pregnancy or not sexually pleasing it 13 or causing obstetric complications: abortion 16,18,21 , abnormal bleeding, 18 hemorrhage, preterm labor, infection, premature amniorrhexis21 and fetal damage. 16,18,21 chological violence perpetrated by an intimate partner was observed to maintain sexual relations during pregnancy 21 and some sexual relations were considered unfavorable by the women when the partner showed no respect for the pregnant body and emotional state. 19eliminary sexual activities were cited in four studies. 13,17,19,21However, only one specified study that they occurred in the form of fantasies and kisses; and three studies by means of caresses. 13,19,21There was a reduction of kisses 21 and caresses throughout gestation 13,21 , and regardless of the type, the preliminaries were considered insufficient to stimulate sexual intercourse. 17

 Category 2 -Sexual positions of pregnant women
In the first study, there was a change from the "man on top" position in the first trimester to "sideways" in the third trimester. 11In the second study, there was a progressive decrease in the use of positions "face to face", "man on top", "lying down", "sitting", "no eye contact", and "woman on top", associated with increased abdominal compression and intense physical exertion of the lower limbs of women.There was a less significant reduction in the "no eye contact", "side by side", "lying", "face to face", "woman lying on her back" and "man aside" positions, disuse of some positions and "side by side" position in the third quarter. 13e adaptive changes in the sexual positions represented a need in the face of pregnancy changes to obtain greater comfort or resulted from the fear of hurting the baby, lack of experience in the accomplishment of sex during pregnancy, nausea, myths and or anatomical alterations. 13

 Category 3 -Domains of the sexual function of pregnant women
In the pregnant woman's perception, there was a reduction in the partner's sexual desire 21 and an increase in the associated female desire to the fact that the partner is more affectionate during gestation, although the ambivalence of feelings regarding motherhood and the exercise of sexuality has been evidenced. 19 the excitation, a more pronounced progressive reduction was identified in the third trimester 13,17,20 and in the first and third trimesters, 12,14,16,18 besides the difficulty for the woman to become involved, to become aroused and to remain concentrated after sexual stimulation. 17garding orgasm, the frequency was reduced 11,12,16,18,20,21 and intensity 13 gradually and more markedly in the third trimester. 11,13,17,20Three studies reported reductions in the first and third trimesters with higher evidence in the third, 12,14,18 two studies reported anorgasmia during gestation. 11,12This domain was negatively affected by the awareness of pregnancy and positively by love in marriage. 16ctors that negatively affect desire, arousal and orgasm have been described: relationship time greater than 10 years, arranged marriages; advanced maternal age; increased number of children, domestic work, responsibility, stress; low education level 14 and employment status 15 , difficulty in establishing communication 13,15 and obtaining information about sexuality in pregnancy with health professionals, 18 concern about pregnancy impairment, 15 decreased importance given to sex in the first and third quarters, 13 unwanted pregnancies, 12-14 decline in importance attributed to age-related sexuality and increase in physical illness; sexual dysfunction; common gestational complaints (pain in the lower limbs and dorsal region, constipation, difficulty in breathing and cramps); low education level and income; multiparity; lack of information and knowledge about one's own body; progress of gestational age; low self-esteem, 15 quality or absence of marriage, expectations derived from the cultural level; presence of medical complications and subjective aspects; 12 vulnerability to popular, sociocultural and religious influences. 19 the other hand, the domains that positively influenced sexual function were information obtained from midwives, close relatives and the internet, 15 effective communication in the relationship, 14 greater capacity for negotiation and adaptation of sexual behavior with the partner, 19 and acceptance of corporal transformations due to satisfaction with pregnancy. 13

 Category 4 -Related aspects to the sexual function of pregnant women
There was a reduction of sexual interest, 13,19 associated with physical or moral violence when pregnancy was not planned or undesired 19 and lack of interest related to the physiological changes of pregnancy, with consequent fear of the partner losing sexual interest. 13During gestation, sexual initiative occurred in a mutual way, 15 with reduction of the sexual initiative of the woman 21 or of both partners, 13 associated with cultural characteristics, self-esteem and anatomical conditions. 1520 Despite being a methodological option, the types of sampling adopted and the use of nonspecific instruments for gestation contributed to the non-uniformity of the results obtained in the studies.Considering the adaptations in the sexual behavior and peculiarities of each gestational trimester, it is pointed out the need to use specific instruments to evaluate the effects of gestation on sexual practices, positions and function. 22 was evidenced that most of the studies did not specify variables aimed at describing the sexual practices and positions, or when they were not explored in detail, as well as for analysis of their influence on sexual function during gestation.Studies have pointed out that during pregnancy, sexual practices and positions are subject to restrictions and adaptations regarding types, frequency, availability and comfort for accomplishment. 5,23 is emphasized that throughout the gestation, the option for other sexual practices in detriment of vaginal sex as alternative forms of seeking pleasure and sexual satisfaction can occur. 24Hugs, intimate touches, massages and licks are also characterized as preliminary practices. 25 with changes in sexual practices and positions, the domains of sexual function declined during gestation with greater evidence in the third trimester.A study that specifically investigated sexuality in the third trimester of pregnancy showed a decrease in sexual activity related to several factors (desire reduction, dyspareunia, physical tiredness, myths, religious beliefs, level of education and information difficulty) 26 , although during pregnancy, they may postpone the puerperium. 27 the primary studies socio-demographic, economic, cultural, religious, physical, psychological, obstetrical, reproductive and affective-sexual factors exerted specific influence in each domain or in general in the sexual function and related aspects, as well as sexual practices and positions.This finding corroborates with a study 28 that pointed out that several factors influencing female sexual function should be analyzed individually and included as part of prenatal care and reproductive health programs.
Prenatal consultations and sexual orientation groups are opportune moments to clarify doubts, conflicts, taboos, fears, support strategies and educational actions aimed at promoting the healthy and pleasurable exercise of sexuality during gestation. 290 The results of this study allowed identifying that there is a reduction in the frequency and/or restriction of the performance of practices and varying sexual positions according to the increase of gestational age.Also, changes in all domains and related aspects of sexual function were evidenced, especially in the third trimester.The sexual practices and positions were not evaluated and/or specified by most of the primary studies, evidencing a knowledge gap.Also, it should be noted that there was no association between sexual practices, positions, and function, which requires studies with this proposal involving pregnant women and their partner in order to better understand sexual function, practices and positions while dimensions of sexuality in pregnancy.
The limitations of this study are related to the generalization of the results, mainly due to the unilateral perception adopted in the primary studies that did not address the partner when analyzing the sexual function, practices and positions in the gestation; as well as to the time cut adopted and the inclusion of different methodological approaches.However, the findings presented contributed to fill in and/or point out gaps on the subject and, therefore, to promote knowledge about the exercise of sexuality during pregnancy, which may help to enable the expansion and/or strengthening of the guidelines offered during prenatal care, in relation to the promotion of sexual health, with a view to reach the integrality and quality of health care.

Table 1 .
MeSH descriptors for the components of the guiding question.
available; language (Portuguese, English and Spanish); type of document (article) and year of publication (January 2005 to April 2017).