' RN

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• Client Assessment
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• ?????? ?????????, ???????????, ???????,???????
  ?????????, ???? ?? ??????? ????, ?? ?? ??????
  ??????????? ?? ????? ??????? ????? ???. ( WHO,
  2002)

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Sexuality is Important to Marriage

• Sexual satisfaction correlates positively with
  marital satisfaction (Christopher Sprecher,
  2000 Oggins et al., 1993)
• Sexual dissatisfaction in marriage can be a
  predictor of divorce early in marriage (within
  first 10 years) (White Keith, 1990)

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??????????, ????? ?? ??????. ?? ??? ????? ???????
????? ???? ?????? ????, ?????? ???? ????? ??
???????? ??????? ?? ?? ??? WHO, 2000
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Sternberg Model of Love(1994)
passion
intimacy
love
commitment
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Sexual Desire
Sexual Satisfaction
Sexual Frequency
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Alternative Cycle of Female Sexual Response
Adapted from Basson, 2001
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• The sexual relationship is the most vulnerable
  during the first years of marriage and even more
  so, during the pregnancy and birth of the first
  child
• von Sydow, 1999

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Thoughts for a successful transition (Not all
about timing and technique)(Elizabeth Davis)

• Self acceptance
• Integration
• Recognition of new role
• Work out birth experience
• Emotional juggle
• Acknowledge change in identity
• Deepen attachment to baby w/ no guilt
• Feel safe and desired by partner

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Pregnancy and Marital Problems

• Escalation in prenatal issues
• Body Image
• Changes in sexuality patterns
• Communication
• Lack of knowledge
• Ambivalence
• Escalation in previous marital strife and
• domestic violence

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Research Agendas(von Sydow, 1999)

• 1950s-1980s How much sex can be allowed
  during pregnancy?
• 1980s Who had intercourse during sex and post
  partum?
• 1990s How does the marital and sexual couple
  relationship develop when the partners become
  parents?

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Old Views of Sexual Intercourse and Pregnancy
(von Sydow, 1999)

• Traditionally the medical system thought
• Cause of infection
• Precipitate labor
• Cause a miscarriage

NO
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Butthe truth is

• In a normal healthy pregnancy
• Intercourse can continue safely till the end of
  the pregnancy
• No evidence that intercourse or orgasm is
  associated with preterm labor
• (Cunningham et al., 1993 Reamy White, 1987
  Sayle et al., 2001)

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Things that may cause enjoyment or discomfort

• Vaginal engorgement
• Breast tenderness
• Vaginal discharge
• Abdominal cramps during or after intercourse

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Central Effects on Sexual Function
5-HT
testosterone(initiation)
estrogen(permissive)
progesterone(receptivity)

Dopamine (DA)
5-HT
prolactin
Norepinephrine (NE)
ORGASM
oxytocin
Modified from Clayton AH. Psychiatric Clinics of
North America 2003 26673-682
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Pregnancy and Sexuality

• Trimester 1
• Trimester 2
• Trimester 3
• (Nussbaum Rosenfeld, 2004)

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Sexuality During Pregnancy and the Year
Postpartum(Hyde et al., 1996)

• Data from Wisconsin Maternity Leave and Health
  Project (WMLH)/ Wisconsin Study of Families and
  Work (WSFW)
• 570 couples (all heterosexual) recruited in 5th
  month of pregnancy
• Funded by NIMH
• Extensive measures of marital quality included
  questions on sexuality
• Longitudinal design followed families over time

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Satisfaction with Sexual Relationship
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Intercourse in Last Month (Hyde et al., 1996)
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Physical and sexual activity during pregnancy and
near deliveryFox, Gelber, Chasen, 2008,
Journal of Womens Health, 1431-1435

• n 435
• 3rd trimester- 62 having sexual intercourse
• 2 weeks before- 40
• 2 days before- 17

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Counseling and educationSexuality During
Pregnancy and Postpartum

• Importance of couples knowing about typical
  patterns
• Importance to physicians

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????? ?????? ????PLISSIT Anon, 1974

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  Information
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• ????? ?????? - Intensive Therapy

• P
• LI
• SS
• IT

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Client Assessment

• Experiences- family affections/values, life cycle
  events, personal
• (home, job),
  previous sexual experience
• Medical history- conditions (health, anorexia,
  bulimia), abuse
• 
  medications, vitamin or hormone deficiency,
• 
  surgeries, chronic pain, mental health
• 
  (depression), trauma
• Personality- locus of control, happy/sad,
  curious,
• self-expression,
  experimentation, creative, sense
• of humor, somatic
• Over-sensitivity- smell, touch, visual/audio
• Worries- fears, concerns (real or imagined),
  financial
• Education- knowledge, source of knowledge, body
  awareness
• Reference point- attitudes, opinions, religious
  beliefs upbringing

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Quality of the Intimate and Sexual Relationship
in First Time Parents Six Months After
DeliveryAhlborg et al. (2005) Journal of Sex
Research

• Low competent relationships deteriorate
• Triad of components affecting new family (Belsky,
  1981)
• Parenthood
• Intimate relationship
• Development of the Child

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Female ChallengeExample Lack of orgasm
Lack of orgasm Insufficient arousal Dislike of
the partner Lack of trust Fear of pregnancy or
STDs Fear of letting go Negative attitudes about
sexual pleasure

• Insufficient orgasm
• Dislike of partner
• Lack of trust
• Fear of STDs
• Fear of pregnancy
• Fear of letting go
• Negative attitudes towards sexual pleasure

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First time Father Study Transition to
ParenthoodCondon ert al. (2004) Australian and
New Zealand Journal of Psychiatry

• N 323 men
• When 23 wks preg f/u 3,6,12 mo. Post
• Highest symptoms during preg with largest
  improvement at 3 months post, little change after
• Sexual functioning deteriorated markedly, little
  recovery at 12 mo.
• Conclusion Men are not prepared!!

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Positions

• Woman on top
• Side lying
• Rear entry
• Sitting

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Why would sexuality decrease with breastfeeding?

• biological E production is suppressed during
  lactation ? decreased lubrication/pain
• prolactin elevated ? decreased sexual interest
• Testosterone lower ? decreased desire
• psychological sexual needs met with erotic
  satisfaction from breast feeding Therefore women
  have less interest in their partners
• social fatigue

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Sexuality in the postpartum
Byrd, 1998
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Resumption of Sexual Activity After Childbirth

• Mutual readiness
• Use of a lubricant
• No heavy bleeding
• No sign of infection

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Postpartum-sexual concerns

• coital taboo - 6 weeks (??), healing uterus,
  infection, lochia
• low libido - high prolactin if nursing, fatigue
• painful coitus - low E causes reduced
  lubrication healing tissues
• milk ejection - orgasm, nipple stimulation,
  milk let down
• sexual arousal, orgasm during nursing,
  infant cuddling and care

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See a doctor if.

• Extreme sensitivity during intercourse
• Repeated bleeding after cessation
• Vaginal tissue seems unusually relaxed
• Difficulty controlling urine

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Intimacy
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41
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Pregnancy and the Postpartum Period

• Pregnancy may be associated with dramatic changes
  (OR NOT!!!) in desire, pain on intercourse, or
  decreased ability to achieve orgasm
• Restoration of sexual functioning following
  delivery parallels restoration of hormonal
  cycling (delayed with breastfeeding), but this is
  a common period for the onset of HSDD (Hypoactive
  sexual desire disorder)
• Possible change in body image (shape of
  pregnancy, full expression of being a woman,
  weight gain, etc.)
• Oruc, Esen, Lacin, Adiguzel, Uyar, Koyuncu 1999
  Glazener 1998 Visness Kennedy 1996

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American College of Obstetricians and
Gynecologists, 2007

• In the absence of contraindications.
• pregnant women should be encouraged to partake in
  regular, moderate intensity physical activity, to
  continue to derive the same associated health
  benefits during their pregnancy as they did prior
  to pregnancy.