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Cuidar no parto luz do modelo da WHO. Perceo das parturientes num hospital portugus
Childbirth caring in the light of the WHO model. Perception of parturient in a Portuguese hospital
Marques, M.
Sim-Sim, M.
Key points
Relembara que o cuidado no parto acontece numa fase muito prxima da experincia
trabalho de parto
Its recalled that childbirth care takes place at a very early stage of the experience,
The study and its analysis leads to question the contexts of care of women in labor
The collection of data from the parturient's perception and the transmission of her
ABSTRACT
Results: Category A represents above all the lack of a birth plan, mobility, massage and
Category B highlights intravenous fluids access, lithotomy position for delivery and
continuous CTG, repeated vaginal examination and episiotomy. Conclusion: The WHO
is not a solitary event for humans. The figure of the midwife to help in the obstetric
and Eccleston, 2015, Montenegro and Rezende, 2014, Trevathan and Rosenberg, 2014).
Midwife assistance, over time and in caring for the woman in labour has led to a
reduction in the rate of illness and death in mothers and new-born children (Rocha and
Novaes, 2010, WHO, 2013, WHO, 2015). In order to improve these indicators,
international organizations create guidelines (WHO, 2015, United Nations, 2015). The
experiences are singularities and gone through by each woman according to her
42+0 weeks gestation and regular labour progress, contemplates spontaneous birth in a
cephalic vertex presentation (WHO, 1996). The first issue to be clarified is the
sense in which the expression "normal birth" is used throughout this paper.
delivery was the object of a clinical study in recognition of the need for its
local and International clarification. (Downe et al., 2001). In this concept, there is
no place for aspects that go beyond the physiological understanding of the term
normal. So there is rejection of elective induction before 41+0 weeks, spinal analgesia
episiotomy and continuous CTG (AWHONN, 2008, Brunt, 2005, Anderson, 2003,
Specializing in Maternal Health (EESMO) has the skills to care for the woman from
admission and during labour. Midwife care and technical-scientific development have
Personalized assistance and freedom of choice, supported by informed decisions, are the
rights of women in childbirth (OE, 2012b, OE and APEO, 2012, WHO, 2013, OE,
2012a).
In efforts over several decades, the WHO has argued for non-medicalized action in
assistance for the low-risk expectant mother (Amorim and Katz, 2012, Rocha and
Novaes, 2010, WHO, 1996). For a normal birth, the WHO guidelines (WHO, 1996)
define obstetric practices in four categories, ranging from useful and to be encouraged
to harmful and to be eliminated. They determine a model which is less intrusive by the
professional and more pro-active by the woman. In this model of assistance, the
resources are used with caution (WHO, 1996, Rocha and Novaes, 2010). Considering
the WHO model, it will be opportune to find out the mothers perspective. The aim of
this study is therefore to describe mothers experience of assistance during labour in the
METHODOLOGY
environment and carried out in an academic context. Data collection took place in the
deliveries represented 72.5% (n=842) of the births. The criteria for selecting parturient
women were: a) low-risk pregnancy (i.e. Norm n 037/2011 of the General Board of
Health), b) single fetus pregnancy, c) Portuguese speakers. Women admitted for elected
nascimentos) e multiplicou-se por quatro meses, uma vez que era, em contexto
acadmico, o tempo disponvel para a recolha dos dados. Obteve-se um total de 388
em participar.
The sample was calculated from 1162 births registered in the referral hospital. The
number of births per month (n = 97 births) was calculated on average and multiplied by
four months, since it was, in academic context, the time available for data collection. A
total of 388 births were obtained. Considering the criterion of Krecje and Morgan
(Almeida and Freire, 2007), a sample was calculated between 165-190 participants and
210 participants were invited to participate. At the time, as individuals entered the
obtained.
The questionnaire was applied at approximately 24hours after the birth, after signing
aspects and obstetric history, and b) a set of dichotomic variables (i.e. yes; no), that
B), avoid (category C) or that are inappropriately used (category D) (WHO, 1996).
The hospital gave permission to carry out the study, following a positive opinion from
RESULTS
Participants aged between 17 and 43 years old (M=30,81; SD=5,31). This was the first
birth for the majority of mothers (N= 101; 56.1%). For 59 participants (32.8%), this was
the second birth and for 20 (11.2%) it would be the third or more. Data from the
Table 1.
n %
Cervical dilation
0-3 131 72.8
4-6 24 13.3
7-9 3 1.7
10 3 1.7
Missing 19 10.6
State of membranes
Complete 120 66.7
Broken 60 33.3
Birthmark
Yes 46 25.6
No 134 74.4
Uterine dynamics
Present 88 48.9
Absent 92 51.1
Gestational age
<37 6 3.4
37-40 142 78.9
41 31 17.2
Missing 1 .6
Note: n=180
The time between being admitted to the health unit and the birth was 13.62 hours (i.e.
13h 37m) on average, with a minimum of 10 minutes and a maximum of 95 hours (3,9
On their own initiative, before leaving for the maternity, they carried out the care
presented in Figure 1.
Care at home
100%
90% 16.9
37.4 31.8
80%
70%
60% 83.7 Yes No
92.2
50%
40% 83.1
62.6 68.2
30%
20%
10% 16.3
7.8
0%
Pubic shaving Shower Microenema Light meal Walking around
The mothers perception is now described, regarding the procedures they were subject
Concerning category A, the presence of the partner (97.2% of cases) and recognition of
privacy (94.4%) is underlined. For a large percentage, the birth plan did not exist as
proposed (i.e. 80.6%) and permission to take light food was not found for 72.6%.
eliminated, the mothers perception was as follows. The majority mention the EESMOs
in delivery in lithotomy (82.9%) and directed pushing ordered by the nurse (86.9%)
(Figure 3).
Category B
100%
26.3 21.9
80%
20%
18.4 17.1 13.1
0%
Microenema Pubic s having Venous fluids Lithotomy Directed pus hing
clear recommendation and which should be used with caution, there is a high
59.9% of mothers.
Regarding category D, containing practices that are frequently used inappropriately, the
Category D
100%
20.8
80%
69.2
60% 78.5No
89.2 Yes
40% 79.2
20%
30.8
21.5
10.8
0%
Continous CTG Suggested epidural Vaginal exam Episiotomy
DISCUSSION
Mothers are subject to practices or paradigms that predominate in the clinic, i.e., in the
institutional culture regarding labour. The procedures expectant mothers carry out at
home, namely pubic shaving, microenema, showering and having a light meal,
reproduce a hospital care model. Therefore, the results suggest that medicalization of
Indeed, the medicalized view centres birth on the health professionals knowledge and
expertise, on institutional norms and routine practices (Rocha and Novaes, 2010, Farver,
2015), but more recent lines of thought tend to centre the process on the woman, on her
preferences and above all on scientific evidence. Perhaps women should be informed
that the physiology of labour is a unique, singular process to be respected in each case
of labour. A discussion of the results follows, in the order they were presented,
The weak representation of the birth plan is manifest. It may be supposed that the
from the labour experience. This understanding and the current results go against human
nature, since there is growing belief that labour manifests itself through the nesting
instinct. As a result of the hormonal environment with increased prolactin and oxytocin,
preparation for birth is an attribute of the species (Coad and Dunstall, 2011, Johnston,
2004). Institutions refusal of Birth Plans and the womans submission to professional
management goes against the typical capacities of this moment in life. On the contrary,
the hospital maternity culture facilitates the exhibition of nesting behaviour (Walsh,
2006). Forming the plan during pregnancy and the expectant mothers visit to the
hospital can contribute to more real birth plan proposals. Knowing the place and the
mothers retain the ancestral species-specific traits of bonds with female figures
(Trevathan and Rosenberg, 2014). The birth plan is an instrument that will foreseeably
become universal in Portuguese hospitals due to the guidelines of the General Board of
The great majority of participants say that their privacy was respected, an aspect to
promote in health units operations, since the lack of this is disturbing and a quiet,
Not infrequently, mothers giving birth are lightly clad, adopt postures, move about, emit
organic groans, lose typical fluids, become excited, agitated or calm down, and show
behaviour generally restricted to the private domain. The presence of unfamiliar people
may be inhibiting and increase stress (Iravani et al., 2015b). In Portugal, management of
the mothers private space is the responsibility of the EESMO and it is important to
restrict access to the birth unit to avoid discomfort, both for the mothers privacy and for
quietness and concentration. The production of oxytocin during labour can even be
interrupted, if stress is high (Odent, 2011). The womans privacy is vital, as she
Most women in this study remained in bed during labour. This is in accordance with the
traditional model of assistance, in which basic care after admission to the institution
includes being given a bed, meaning a space for her to occupy (Jansen et al., 2013).
Lying in bed does not facilitate labour (Coad and Dunstall, 2011, Montenegro and
Rezende, 2014). Mobility and movement shorten the first stage of labour by
approximately one hour twenty minutes on average (Lawrence et al., 2013). Changing
foetus to the upper and lower channels, as well as a flexible position and thereby better
presentation of the cephalic diameters to the diameters of the maternal pelvis. These are
contributions to the obstetric dilemma inherited from human ancestry. It is also of note
that there is less probability of a Caesarean, less use of epidural and pain management is
The great majority of women did not take in food during labour, in accordance with the
to suck and clear liquids in tiny amounts have been offered (Jansen et al., 2013, Sharts-
Hopko, 2010). Food restriction originates in the knowledge of Mendelson spread in the
1940s (Sharts-Hopko, 2010, Singata et al., 2010, Singata et al., 2013). However,
revisions of random studies conclude there are no benefits or significant threats that
justify the restriction of liquids and food in low-risk women (Singata et al., 2013). In the
mother with nutritional deficiency, labour can be prolonged and more painful, besides
fasting not guaranteeing an empty stomach (Singata et al., 2013). Labour requires an
effort of 295Kcal on average (Maganha e Melo and Peraoli, 2007) and current belief is
that it is the woman who can best judge the need to ingest (Singata et al., 2013). This is
The presence of the companion, generally the husband, is mentioned by the great
majority of women, respecting the human condition and legal aspects. The presence of
the partner has been part of legislation for more than 30 years in Portugal and is not
(Farver, 2015). This is human adaptation to evolution and is common in almost all
cultures. Humans do not give birth alone, unlike non-human primates (Dunsworth and
Eccleston, 2015, Rosenberg and Trevathan, 2002). The partner is the person who has the
greatest emotional link to the woman, compared to professionals who, although they
may accompany, are emotionally unknown. The potential benefits that the beginning of
the link brings to the triad in terms in terms of co-parenthood should also be considered.
Massage is referred to by less than half the women. The results suggest a lack of
knowledge or unavailability of the partner or EESMO, with the benefit being lost. No
Massaging the expectant mother is also a naturally human initiative, as faced with the
suffering woman, the companion will have the intuition to warm her, to touch and
massage.
becomes possible. This stabilizes the cardio-respiratory rhythm of the new-born child,
reduces crying, lessens the probability of feeding with a formula, strengthens the
temperature and being a factor in reducing the childs stress (Moore et al., 2012, Stevens
et al., 2014). Even in cases of Caesarean birth, these forms of care should be encouraged
Association, Maternity with Quality, with early skin-to-skin contact being one of the
number of women who performed the enema is high, and the number of women
carrying out microenema was high (i.e. reaching 64; 36% of the sample). Enema is
inappropriate as preparation for a normal birth and is performed according to the health
natal infection, nor in the length of labour (Cuervo et al., 2000, Reveiz et al., 2013). In
this study, the 64 participants were not subject to enema, but to microenema, i.e., rectal
administration of 5-10 ml of sodium citrate and sodium lauryl sulfoacetate, with contact
laxative properties, which produces freeing of the water with liquefaction of the faecal
material. In fact, the literature does not reveal systematic reviews exactly about this
form of microenema.
Regarding pubic shaving, the great majority of women performed this on their own
initiative at home (n=149; 83.7%) and of those who did not do so at that time, it was
The understanding in favour of pubic shaving defends the idea of hygienic, prevention
operation of instrumental birth from below (Altaweli et al., 2014, Basevi and Lavender,
Studies do not confirm positive results and mention discomfort through growth of pubic
hair, irritation in the vulva area, multiple superficial cracks, burning sensation, heat and
itching (Basevi and Lavender, 2014). Another aspect, rarely approached, has to do with
have a mature, adult image. Removing pubic hair makes the powerfully reproductive
posture, leg-strengthening, exercises on all fours, use of the ball or other instruments,
clinical reasons or due to maternal ketosis. Nevertheless, care should be taken, as this
can cause breast edema and affect breastfeeding, overload liquids diminishing uterine
2013).
position with stirrups in their experience during labour. In Western society, this has been
the instituted position since childbirth moved to a hospital environment (Gupta et al.,
2012). The results of this study are removed from the WHO recommendations and the
results of the Cochrane revisions. The evidence shows the benefits of verticalized
positions in mothers without epidural, although blood loss can be above 500ml.
Considering the womans interests above all, it will be up to her to choose the most
comfortable position for delivery (Gupta et al., 2012, Kemp et al., 2013).
Around 87% of the mothers state that the pushing efforts were managed by the EESMO,
stretching, causing the release of endogenous oxytocin from the receptors of the vaginal
tract (Coad and Dunstall, 2011). In directed pushing, the mother is instructed to hold her
breath and make perineum pushing efforts, until the end of the contraction. In
spontaneous pushing, she makes pushing efforts according to the urgency she feels in
her body. The results of this study contradict the WHO recommendations (WHO, 1996)
and the evidence, with no greater benefit being found in directed pushing. Women
should be encouraged to act according to their preferences and the singularity of each
clinical situation will guide decisions as to the type of pushing (Lemos et al., 2015). In
this study, the majority of women carried out epidural, which may have contributed to
(Montenegro and Rezende, 2014), was recognized by around 60% of the women. There
are potential risks for the mother, such as, uterine rupture, tearing of the anal sphincter,
and situations of dyspareunia and perineal pain. Other less common risks to the mother
include fractured ribs, abdominal, haematomas, liver or spleen damage, and utero-
overian pedicle damage (Sartore et al., 2012). For the child the risks are cerebral
(Sartore et al., 2012, Verheijen et al., 2009). The Kristeller Manoeuvre has created
controversy, as professionals do not agree about orientations that reject routine use
(Sartore et al., 2012). In Spain there is a recommendation not to apply it (i.e. Guides for
clinical practice in the NHS. 2011; p. 148). In France, guidelines say there are no
publication rejects its routine use (OE and APEO, 2012) e outros autores, colocam a
entanto para o facto de nao ser inofensiva, pois poder afetar a contratilidade uterina e
levar a uma hipertonia com efeitos prejudiciais sobre o feto. POder ainda causar o
observa-se que quase todas as parturientes reconhecem que o mesmo foi aplicado
technician, warning that it is not harmless, as it may affect uterine contractility and lead
to hypertonia with detrimental effects on the fetus. It may still cause the placenta to
prematurely dislocate and even amniotic embolism (Montenegro and Rezende, 2014).
Regarding Category C, we begin the discussion with the application of the continuous
CTG, it is observed that almost all the parturients recognize that it was applied
(89.2%).The results agree with, but are higher than those found in other research
(Lothian, 2014). This may mean relegation of clinical knowledge, in favour of data
provided by electronic equipment, or a care model with less physical presence of the
evidence of benefits for low-risk women (Devane et al., 2012). Carrying this out on
entry to maternity represents a defensive style of care, but adds 20% to the probability
The WHO recommends this should not occur with low-risk women continuously
throughout labour (WHO, 1996). It does not seem to bring benefits over intermittent
monitoring.
Epidural was suggested by EESMO in 20.8% of cases and was used by 61.5% (n=110)
of the women, representation being therefore close to American studies (Lothian, 2014).
As a means to alleviate pain, it is widely used and can be incorrectly included in the
concept of a normal birth (AWHONN, 2008). In women with epidural, the absence of
pain leads to a fall in endogenous oxytocin and the need for synthetic oxytocin. This
synthetic form does not cross the haemato-encephalic barrier and there is no release of
endorphins. Relaxation of the pelvic muscles interferes with the fetal fall, as the cardinal
movements are difficult to achieve, besides the higher risk of occiput posterior
presentation (Lothian, 2014). Instrumental birth is therefore frequent. Indeed, pain is the
womans greatest fear and the perspective of the epidural can give confidence.
administration of oxytoxic perfusion, motor block, a drop in blood pressure, a bad fetal
position, a longer delivery, retention of liquids and greater use of forceps or vacuum
protecting against stress in the perinatal stage and therefore affects the mothers
The vaginal examination is considered next, and repeated occurrence was referred to by
labour (Downe et al., 2013, Jansen et al., 2013), which should be used sparingly
(Downe et al., 2013). There is a risk of chorioamnionitis and puerperal infection, with
the observation that seven or more vaginal examination make the new-born child 4,5
times more likely to contract infection (Jansen et al., 2013). It is an intrusive procedure
that can make the woman feel physically and emotionally uncomfortable, besides
Finally episiotomy, which is recognized by 117 women (69.2%) and confirms data from
other studies (Lothian, 2014, Melo et al., 2014). It is a procedure requiring the
competence of the EESMO regarding the decision to perform it and the correct moment.
et al., 2014) and is recognized in Portugal as a practice to be avoided (OE and APEO,
2012). The indication remains that it should not exceed 10% (Melo et al., 2014, WHO,
There are health gains if expectant mothers are informed about the benefits of non-
medicalized labour.
The material for classes to prepare for childbirth should prioritize contents that favour
EESMO should emphasize their competence, knowledge and expertise in care for
expectant mothers.
CONCLUSION
woman and the quality of services. Bringing this topic into the open may contribute to
greater efforts and dedication in care related to the physiology of childbirth, plus an
Organization.
As far as could be gathered from the bibliography, this is the first Portuguese research to
should be borne in mind that this is a small study, of a local nature and carried out in an
academic context.
Given the guidelines defined by the WHO and the current scientific literature, the need
for change is confirmed.It will be necessary, during classes. Ser necessrio, durante as
classes de preparao para o parto, recomendar as mulheres que optem por abandonar a
sua realizao em casa, antes da deciso de ir para o hospital, pelo perigo de tricotomia
abandon the idea of childbirth at home, prior to their decision to go to the hospital, of
the danger of perineal or enema trichotomy. These are practices that have long been
promoted, with the justification of better hygiene, the best healing and possible
practices with significant representation in this study. Parturient mothers do not apply
their capacities to deal with labour, given the use of interventions that are removed
from, or disturb the physiology of the phenomenon. If women wish to receive quality in
obstetric care, it is important that they are informed by EESMO and that clinical
practices are implemented based on evidence. Some measures to modify the practices
of ESMES could be directed to the realization of continuous formation and the creation
adhesion to practices that both ensure the safety of EESMO operations and provide
parturient mothers with quality.. Um estudo mais abrangente em uma amostra aleatria
pode ser importante, antes e aps o treinamento A broader study with a random sample
could be important before and after training. Excellence of care facilitates the normal
physiology of labour.
References