Association between non-invasive nursing care technologies during childbirth and neonatal vitality: a cross-sectional study

Objective: to compare the use of non-invasive midwifery care technologies (TNICEO) with the use of traditional care model practices, having as parameters the presence of meconium in the amniotic fluid and its repercussion on the newborn’s vitality. Method: a crosssectional study with secondary data of 10,219 parturients who delivered by midwives between September 2004 and October 2016. Logistic regression was used to assess Apgar> 8 Odds Ratio in exposure to noninvasive midwifery care technologies when compared to traditional care. Results: there were higher percentages of light amniotic fluid and neonates with good vitality in parturients who used only TNICEO compared with those exposed only to traditional care. Conclusion: nurse midwives’ provision of TNICEO and its use by women are efficient strategies to reduce unfavorable neonatal outcomes. Implications of practice: investments in the performance of these experts is important, as their know-how to make them not medicalized through TNICEO confirms a process of humanized, safe and quality care that meets official recommendations and contributes to the change in the care model.


INTRODUCTION
Elimination of meconium in amniotic fluid is a relatively common finding during parity in women classified as having a habitual obstetric risk. However, considering that the mechanism by which the fetus eliminates it may be associated with several pathophysiological factors, assessment of amniotic fluid characteristics during labor has been shown to be an important component for the assessment of fetal and neonatal vitality. 1,2 There is consensus that the presence of meconium in the amniotic fluid does not, by itself, characterize fetal distress and is a warning sign for surveillance of maternal and fetal well-being, as well as for the risk of aspiration by the newborn at birth. 3,4 In some cases, this may have a negative impact on women's health and newborn vitality. 4,5 Unfavorable outcomes are found by decreasing fetal heartbeat, Apgar score less than 8, or by reducing blood pH at birth, with significant impacts on perinatal morbidity and mortality indicators. 1,[5][6][7][8][9] In obstetric practice, according to the traditional care (TC) model, it is observed that the presence of meconium in the amniotic fluid drives the adoption of interventional conducts or is a consequence of procedures based on outdated scientific evidence. Thus, this type of care does not always represent safety or is a protective factor for maternal and perinatal health, adding more risks than benefits to women, fetuses and newborns. 1,[10][11][12] This close correlation is revealed, for example, in the association between the routine use of oxytocin and the higher incidence of meconium elimination by the fetus, as well as caesarean sections. [3][4][5] On the other hand, nurse midwives, inserted in the not medicalized model of care at childbirth and birth, have shown concern about the characteristics of amniotic fluid as an important indicator for their professional performance. These experts understand that the higher incidence of light amniotic fluid with missing meconium and lower risks to maternal and perinatal health are related to a care process. This care is humanized and respects the physiology of parity and uses obstetric practices recommended by the World Health Organization and the Brazilian Ministry of Health. 13,14 It is noteworthy that nurses, by redirecting women's care to a not medicalized perspective, re-signified the official recommendations of "best practices" from the construction of specific knowledge called non-invasive midwifery care technologies (TNICEOtecnologias não-invasivas de cuidado de enfermagem obstétrica). TNICEO are a technological breakthrough as they are soft and relational technologies that have incorporated new meanings in childbirth and birth care. 15,16 Corroborating the broadening of the conception of nursing care, in its different dimensions, TNICEO can be seen as a structured knowledge, applied with intentionality and justification, which produces results that meet the objective and subjective needs of human beings. 17 In the nursing field, TNICEO are defined as a set of techniques, procedures, knowledge and knowledge developed and used by nurse midwives in caring for women. 15 In this context, besides being configured as a strategy for parity de-medicalization 18 , the use of these technologies seems to be related to the decrease in the rates of fluid meconium amniotic fluid and the risk of tracheal aspiration at birth. 12 In this sense, it is believed that with the use of TNICEO there is a lower risk of newborns being bathed in meconium amniotic fluid and greater odds of having good vitality at birth (Apgar >8).
Given the above, this study aimed to compare the use of noninvasive technologies of midwifery care with the use of practices of the traditional care model. The presence of meconium in the amniotic fluid and its repercussion on the newborn's vitality were parameters used.

METHOD
A cross-sectional study with secondary data, performed at a maternity hospital in the city of Rio de Janeiro. This institution is a reference for pregnant women at usual risk and lives with a hybrid model of care at birth and birth. There is a coexistence of professionals who use humanized practices to encourage normal childbirth and the protagonism of women, as well as adherents of the traditional obstetric care model. This model is characterized by the predominance of biomedical knowledge, often determining interventionist and medicalized behaviors. 11 The study population initially consisted of 10,675 records of vaginal births. All were followedup by nurse midwives from 2004 to October 2016. Of this total, 456 records were excluded due to lack of data on the use of TNICEO, TC or both, ultimately totaling 10,219 births for the study.
In the research field institution, nurse midwives only follow births without any complications. Therefore, the use of any procedure related to traditional care was the decision of the nurse midwife, considering the circumstances of the moment of childbirth. It is also worth mentioning that this is an institution where there is hegemony of the medicalized model and TC. Thus, this environment can influence the decisions of nurse midwives by adopting procedures related to this care model.

Non-invasive childbirth care technologies
Vargens OMC, Reis CSC, Prata JA, Oliveira AMG, Progianti JM The data collection source was the book called "Livro de Registros de Partos" (Birth Records Book). This is an institutional form designed to document information regarding care provided by nurse midwives during labor and childbirth at the obstetric center of the maternity ward. Data were stored in Epi-Info software, version 6.04D, 2001.
For the purposes of this research, we considered the following information recorded in this form: interventions and/or care to which parturients were exposed during labor and childbirth; presence of meconium amniotic fluid identified and clinically assessed by the nurse midwife during parity; Apgar (clinical assessment of the newborn in the first and fifth minute of extrauterine life) determined by pediatrician or neonatologist.
These data were entered into an electronic bank and, using statistical resources, three exposure variables were established: a) TNICEO, which included parturients who used only these technologies, regardless of type and quantity such as: stimulation of ambulation, use of obstetric bench, warm water spray bath, relaxing massage, stimulation of pelvic movements, aromatherapy, breathing exercises, use of physioball, encouragement of the participation of the companion, lateral decubitus, squatting position supported, option for the position of four supports; b) Tc, with the inclusion of parturients exposed exclusively to the procedures commonly used in the biomedical care model, regardless of the type and quantity used, namely: intravenous infusion of exogenous oxytocin, amniotomy, episiotomy and reduction of the cervix; c) TNICEO + traditional care, covering parturients exposed to both forms of obstetric care, regardless of the type and quantity of technologies and/or procedures used.
Regarding outcomes, Apgar was considered in the first and fifth minutes of life, attributed by pediatricians who served neonates after birth. This index is obtained by observing five objective clinical signs: heart rate, muscle tone, reflex irritability, skin coloration and respiration that can receive 0, 1 or 2 points each. Total score ranges from 0 to 10 points. 19,20 These indexes were registered in the electronic bank and were later divided with the resources of the statistical package into two groups, from 0 to 7 and from 8 to 10. 8,9,21 The group with Apgar score between 8 and 10 showed good vitality at birth (first minute Apgar) and good extrauterine adaptation (fifth minute Apgar).
The confounding variables included in the analysis were those recorded in the book "Livro de Registros de Partos": risk classification, number of pregnancies, parity, amniotic fluid characteristics, and newborn birth weight. Data not filled in or not informed were considered as information losses for each variable studied, which can be verified by the total of each variable in the results.
Statistical treatment involved the use of descriptive statistics and logistic regression. Chi-square test was used considering significant p values less than 0.05.
For each outcome two logistic regression models were constructed. In the first model, all statistically significant confounding variables were included in the bivariate analysis results. In the final model, only the statistically significant variables observed in the results of the first model were included. In both models, odds ratio (OR) cross-product were estimated with 95% confidence intervals (95% CI) and p value <0.05. The

RESULTS
Regarding the characterization of parturients, of the 10,219 childbirths followed up by nurse midwives in the maternity hospital studied, 27.4% were adolescents aged 10-19 years. 39.1% were primiparous, 42.9% primiparous and 72.6% served six or more prenatal consultations.
Regarding the types of care provided by nurse midwives and used by women during parity, 97.2% of parturients used some form of TNICEO. Of this percentage, 43.9% used only these technologies, 53.3% made use of TNICEO and also underwent traditional care practices. On the other hand, we highlight the percentage of parturients assisted by nurse midwives who, alone (2.8%) or associated with TNICEO (56.1%) were exposed to at least one TC-related procedure. Table 1 lists some of the techniques and resources that make up the TNICEO group most used by parturients during labor and/ or childbirth. It is noteworthy that a parturient may have used one or more of the technologies provided by the nurse midwife.
Regarding the procedures that make up the traditional obstetric care, intravenous infusion of oxytocin solution was the most employed (44.9%), followed by amniotomy (22.6%) and episiotomy (14.9%).
In this study, the record of amniotic fluid characteristics was found in 9,817 parturients. the presence of meconium was identified in 14.9%, being 13.9% of fluid meconium amniotic fluid and 1.0% thick meconium. When amniotic fluid characteristic was assessed by the type of care used by parturients, higher percentages of the presence of meconium (fluid meconium and thick meconium) were found in the group of women undergoing traditional care alone (20.8%) or in association with TNICEO (15.3%). On the other hand, when only TNICEO was used, these percentages dropped to 14.0% (Table 2).    When comparing Apgar variables and amniotic fluid characteristics in relation to the use of TNICEO or TC, it was found that in the first minute of life of newborns whose mothers used only TNICEO, 94.5% had Apgar> 8 (good vitality) at birth. It was a significantly higher percentage than the 80.9% found for the group of newborns whose parturients underwent only TC (Table 3).

Non-invasive childbirth care technologies
Vargens OMC, Reis CSC, Prata JA, Oliveira AMG, Progianti JM Analyzing the results related to the fifth minute of life of newborns (adaptation of the extrauterine environment), there was also a higher incidence of Apgar> 8 in the parturient group. They used only of the TNICEO provided by nurse midwives when compared to the group that used only the conducts related to traditional care, 99.2% versus 95.0% (Table 3).
After controlling for confounding variables, it was found that the results of the second regression model or adjusted final model (OR 3.650; 95% CI 1.633 -8.159; p value 0.0016) showed that Apgar OR in the fifth minute of life is equal to or greater than 8 is increased for the group of newborns whose women used only TNICEO during parity. This occurred when compared to parturient newborns who underwent traditional care procedures ( Table 4).

DISCUSSION
Regarding the characterization of women followed by nurse midwives during parity and birth, the results of this research revealed the significant incidence of adolescents (27.4%), primiparous (39.1%) and primiparous (42.9%), which are similar to those found in other studies [22][23][24] . These findings are commonly associated with early hospitalization and the adoption of interventional approaches, such as intravenous infusion of synthetic oxytocin, amniotomy and episiotomy, indication for cesarean section, among others described in the TC model. 23,25 Regarding the records of prenatal care, it was found that 72.6% of parturients served six or more consultations, meeting the official recommendations and approaching the percentages presented in studies conducted in different regions of Brazil 23,24,[26][27][28][29][30][31] . This data points to the expansion of access and coverage. However, the significant drop in prenatal care adequacy rates, as well as the persistence of regional inequalities related to quantitative health care indicators, should be considered. 23,24,27,28 The commitment of nurse midwives with de-medicalization of childbirth and birth was evidenced, despite their performance in an environment strongly influenced by the hegemonic medicalized model. 97.2% of parturients used some TNICEO alone (43.9%) or associated with some procedure of the traditional obstetric care model (53.3%). In this perspective, the practice of these experts in hospital care is proving to be an efficient strategy for qualifying care for women at usual risk, as well as for reducing interventions in risk situations, when the institution adopts a collaborative professional model of obstetric care. 18,30,32 Comparing the practices used by nurse midwives in this research with the results of other studies, it is clear that experts offer women different options for parity. There is a highlight for stimulating breathing exercises; encouraging the active participation of the companion; stimulation of free movement; use of warm water in the sprinkler bath; and massage. 11,25,29,30 These resources, when used from the perspective of respect for the physiology and female autonomy of non-invasion and protagonism, characterize TNICEO. TNICEO converge on shared construction of a not medicalized, woman-centered care that predominantly uses light technologies and meets the World Health Organization and the Ministry of Health recommendations. [12][13][14]18 On the other hand, the association of the use of TNICEO with typical traditional obstetric care procedures and procedures in 56.1% of parturients reveals that, despite the institutional commitment and effective participation of nurse midwives in childbirth rooms, the model still persists. hybrid of attention to childbirth and birth. There is a coexistence of not medicalized and interventionist practices. 11,12,27,30,32 As an effect of this configuration, the performance of amniotomy (22.6%) and episiotomy (14.9%) appear as part of the assistance of nurse midwives to women at usual risk, with oscillating percentages compared to those presented in other studies. 18,29,30,32 Regarding the intravenous infusion of exogenous oxytocin, administered in 44.9% of parturients, the present study shows a result lower than 57.7% of a study conducted in maternity hospitals in Belo Horizonte. However, this percentage is higher when compared to the 30.8% found in a normal childbirth center in the same city 19 , as well as the 40.0%, 41.8%, and 18.9% of studies conducted, respectively, born in Brazil25 maternity hospitals in the states of Rio Grande do Sul and Ceará. 29,30   Although it is common to have no records on the indication for oxytocin use, such conduct, in most cases, comes from medical interference in the field of practice of nurse midwives. 30 In addition, it should be considered that such procedure, regardless of indication, may cause iatrogenesis and, when used routinely, is associated with the elimination of meconium in the amniotic fluid. 1,4 Therefore, it is recommended that the prescription of oxytocin be careful and avoided in cases of meconium amniotic fluid and fetuses with evidence of hypoxia. 13,14 Regarding the correlation between amniotic fluid characteristics and type of care, the presence of meconium (fluid or thick) was found in 14.9% of childbirths followed by nurse midwives. It was a percentage within the range of 10 to 16% cited by other authors, but higher than 8.1%, from a survey conducted in a maternity in the Northeast region. 29 The 11.9%, found in a study that had as scenario a normal childbirth center of the Southeast region. 3 For the nurse midwives in this study, the presence of meconium amniotic fluid alone was not a hindrance to followup of parity and birth. For decision-making, they consider joint analysis of other factors such as fetal static, labor evolution conditions (uterine dynamics, uterine cervix changes, and fetal progression in the pelvis) important, as well as monitoring fetal vitality.
It was possible to evidence lower indices of the presence of meconium in the amniotic fluid of parturients who used only TNICEO (14.0% versus 20.8%). The type of care used affects amniotic fluid characteristics. Both in fluid form (13.0% versus 17.8%) and in thick form (1.0% versus 3.0%), the effects of TNICEO use are more beneficial when compared to the use of procedures of the traditional obstetric care model. This finding, besides reinforcing the importance of cautious use and the adoption of precise indications related to interventional obstetric practices, reveals that the use of TNICEO translates into safe and quality care. TNICEO uses the best available scientific evidence and meets current care guidelines for improving maternal and perinatal indicators. 2,4,13,14 Regardless the cause of meconium clearance, data in Table 3 show that their presence in amniotic fluid is associated with Apgar scores less than 8 in the first and fifth minutes of newborn life. This result is consistent with the findings of a study conducted with women of full-term and usual-risk pregnancy. It demonstrates that the presence of meconium in the amniotic fluid showed higher rates of adverse perinatal outcomes 33,34 .
In this correlation, the influence of the type of care available to the parturient during parity stands out. When women are exposed only to traditional obstetric care practices, the percentage of infants born with meconium bathing and with poorer vitality (45.2%) is more than double that of newborns of those who used only TNICEO (22.0%).
As shown in Table 4, odds ratios of newborns showing good vitality in the fifth minute of life (Apgar greater than or equal to 8) are higher when nurse midwives resort only to TNICEO for the parturient care process, as well as the presence of meconium in the amniotic fluid reduces such odds.
Corroborating with similar results, other studies describe that although the presence of meconium in amniotic fluid is not a determinant of fetal distress, this finding is related to traditional obstetric care, lower Apgar score, and unfavorable neonatal outcomes. 2,4,12,24 Given the results of adopting interventionist practices in childbirth and birth care, the benefits of using TNICEO are reiterated. These are essential care for women's care demedicalization that contribute to reduce the incidence of meconium elimination by the fetus in the amniotic fluid, as well as associated with the birth of neonates with good vitality (Apgar> 8) in the first and in the fifth minute of extrauterine life. 11,12,15,18,30 CONCLUSION It is concluded that the availability of TNICEO by nurse midwives and their use by parturients during parity and birth are efficient strategies to reduce unfavorable neonatal outcomes. Compared with the use of traditional care model practices, they present better perinatal results regarding the parameters presence of meconium in the amniotic fluid and its repercussion on newborn vitality.
However, the present research also pointed out that, despite the transformation of the obstetric care model underway in Brazilian public institutions, there are still practices not consistent with the proposal of humanization of care. Conducts considered harmful or inappropriate were evidenced to the detriment of those recommended by official guidelines and recommendations that are based on the best available scientific evidence.
Even though some nurse midwives still include procedures related to traditional care in their practices, these professionals are among the main drivers of public policies aimed at promoting changes in health services. The results of this study reaffirm the importance of investments in the performance of these experts in childbirth and birth care. The not medicalized know-how through TNICEO conforms to a humanized, safe and quality care.

Non-invasive childbirth care technologies
Vargens OMC, Reis CSC, Prata JA, Oliveira AMG, Progianti JM Regarding the limitations of the study, the most important are related to the fact that it is a cross-sectional study with secondary data whose data collection tool was elaborated from existing information records. However, the fact that the newborn Apgar score was always recorded by the pediatricians who served them was an important reliability indicator of these results.
In light of the above, we suggest further studies on the effectiveness of the use of TNICEO in women's health care. Especially prospective studies should be conducted, with a view to aggregating scientific evidence to support these technologies, giving greater visibility to midwifery practices in the health field and enabling overcoming the limitations found here.