Prática educativa com enfermeiras visando o cuidado humanizado ao recém-nascido no centro obstétrico

Resumen pt: Relato de experiencia, objetivando descrever o desenvolvimento da pratica educativa realizada com enfermeiras para elaboracao de proposta de cuidados dir...


INTRODUCTION
The area of obstetrics and care of the newborn has always aroused interest, in particular the moment of birth, one of the most intense moments experienced in the life of the couple and of the newborn (NB), bearing in mind its transitional, maturational, and complex character, striking for those involved.
Birth is especially delicate for the NB, who faces a universe which is distinct from that existing in the maternal uterus.In leaving the intrauterine environment, contained and protected, the NB takes her first steps towards her independence, and will need to adapt definitively to the extra-uterine environment, which is different and unknown.Thus, it is a critical moment from the emotional and social point of view, and from the perspective of risk and vulnerability of life. 1 In spite of technical-scientific progress, in spite of the organization and improvement of the care having created significant transformations in the care of the NB over time, with the consequent reduction in child mortality, the rates of neonatal mortality remain high.In 2008, neonatal deaths were responsible for 68% of deaths in children 2 and, of this percentage, between 25 and 45% occur in the first 24 hours of life.Thus, the adequacy of the care for the NB has been one of the challenges in reducing these rates in Brazil. 1,3uring the neonatal period, there are biological, environmental, psychological, socio-economic and cultural risks, making it necessary to establish special care and action which is opportune, comprehensive and qualified, for social and health protection for this part of the population. 1 Besides the concern with reducing risks, it is fundamental for the NB to be received harmoniously in a welcoming environment, above all in the first 24 hours of life, by the parents and health team, such that it may adapt the world and, in future, achieve development in biopsychosocial dimensions.
In this way, another challenge, no less important, is to consolidate the good practices proposed by the Pan-American Health Organization (PAHO) and by the World Health Organization (WHO). 3These good practices relate to forms of care which are safe, apprehensive, qualified, scientifically-based, centered on the NB and her needs, aiming to promote her health and full development, encourage the bond between mother and child, prevent complications and avoid unnecessary interventions. 1 The transitional process sometimes occurs in a hostile form depending on the environment, on who receives her, on the people with whom the NB interacts, and on the care provided, situations which can influence -facilitating or hindering -the early mother-baby bond, consisting of inappropriate care which is contrary to the good practices which influence the NB's adaptation.The literature shows that the reception and the way of undertaking the care for the NB can be differentiated, in accordance with the model of care adopted by the institution, possibly being technocratic, technique-or biology-centered, or humanistic, centered on the human being. 4he care provided by the health professionals to the NB immediately following birth is fundamental for her adaptation to the new life, to her interaction with her parents, to her physical and psychological development, and to the reduction of neonatal morbidity and mortality. 4he nurse, as a member of the neonatal team, has as her responsibilities to facilitate, encourage, and propose actions for improving attention to neonatal health, avoiding practices considered inappropriate and encouraging good practices with a view to safe, quality care, which satisfies the client and the health team. 5The nurse, in the team, has the role of being the person who articulates the care in the interactions with the parents and various members of the team, and it falls to her to suggest forms of providing care. 6n the routine of the care for the NB, there are divergences in relation to the care provided by the health professionals, in accordance with the distinct models of care, relating to how the technique itself is conducted, to the timetabling, the materials and the drugs used, which aspects also diverge from what is recommended in the literature.These divergences are little explained, reflected upon or discussed in the ambit of the work, being undertaken routinely, without there being a consensus from the health team and an up-todate, scientifically-based proposal for conducting the care for the NB in the Obstetric Center (OC).
Thus, the nurses who participated in the workshops, based in these divergences, proposed, as a strategy for reverting this situation, the construction of a proposal for guiding the care, which should be congruent with the newborn's needs.
Based on the above and on the assumptions made by Freire, 7 for whom knowledge is something mutable and unfinished, which is constructed and reconstructed based on the problematization of the concrete context in the space of the relationships, through dialogue and the critical and reflexive analysis of the cognizant subjects, it was agreed with the nurses of the OC to undertake the collective development of an educational prac-Müller EB, Zampieri MFM tice, with the aim of reviewing and reconstructing the way of conducting the care provided in the OC to the NB, based on good practices.
The educational process, in a dialogic and problematizing perspective, according to Freire, 8 is flexible, dynamic, complex, reflexive, therapeutic and ethical. 9It occurs based on the interactions between human beings, there being exchanging of knowledges, experiences and values.In this, the person who teaches learns, and the person who learns, teaches. 8It can be an instrument of transformation, construction and reconstruction of the context, of stances and attitudes, making the world and history more humane. 9ealth education can be a political and pedagogical process which allows the development of a critical and reflexive way of thinking, and increases human beings' autonomy, as it makes possible for the latter the construction and production of a knowledge with which they are able to propose changes and make decisions regarding the care for the collectivity. 10A personal and professional commitment is established, which awakens understanding regarding the importance of involvement and responsibilization and which empowers the professional to develop technical and humanistic competences, to improve herself and to propose changes in conduct in her work context. 11hus, this article aims to report how the educational practice undertaken with the nurses was developed, for the construction of a proposal for care directed towards the newborn in the Obstetric Center of a public hospital, based in good obstetric and neonatology practices, based on the divergences between the care provided to the newborn by the health professionals, and those existing in the literature.

METHODOLOGY
This is an experience report on educational practice, describing the stages experienced by the group, indicating the strategies used, the consensuses in the construction of the proposal for care for the NB, and evaluation of the process.
] The subjects who participated, chosen intentionally, were the nurses who work in the OC of the maternity department of a public hospital in the south of Brazil, who were invited personally and by an invitation placed on the department wall.This initiative was considered by the institution as a means of training these professionals.A total of seven nurses participated in the educational practice, of the eight working in the OC.All have worked in this area for over nine years.Of these, six are specialized in obstetrics and one in public health/family health; four of them have M.A.s, one a doctorate, and another is concluding her doctorate.The educational practice was started in October 2011 and concluded in April 2012.
Preceding the educational practice, in September 2011, a preliminary survey was undertaken through a questionnaire with a group of nurses of the OC, so as to investigate the divergences relating to the care provided for the NB in the OC and to gather suggestions for overcoming them.The divergences revealed on the occasion referred to the different ways of conducting the care, centered on the technique or on the NB and on her needs; there being disagreement in relation to times, steps, materials, medications and the place for providing the care.In addition, unnecessary interventions and inadequate practices were revealed, opposing the scientific bases and the needs of the mother-NB-father trinomial, with the following standing out: a) the birth and the care for the NB were not always undertaken in an embracing environment, occurred in a routinized form, prioritizing technique, and the professionals' interests and needs, with unnecessary interventions; b) the time for skin-to-skin contact and the respect for forming the bond between the parents/NB were not followed by all the professionals; c) the clamping of the umbilical cord was done early; d) the NB's bathing diverged in relation to technique, the use or not of antibacterial soap, and the place and time to be undertaken; and e) the techniques for administering the credé method and the administration of konakion were done in different ways.
The divergences served to start the debates and were considered in the group, during the educational practice, and were added to by the divergences found in the literature.These data, added to the studies on good practices for the NB, supported the reflections in the workshops.
Six workshops were undertaken, four of which were used for working on the divergent points, and to define paths and consensuses.For the operationalization, the first four workshops were organized in seven stages: 1 st ) Embracement: a period for preparation of the environment and embracement of the participants.2 nd ) Interaction and sensitization: to interact with and raise the awareness of the participants.3 rd ) Planning, validating and defining paths: the period in which was presented the work proposal of the day, approved by the group, a summary was made of the previous workshop, and the consensuses arising from the reflection and group discussion were validated.4 th ) Problematizing the issue: the point at which the central theme was worked upon.The divergences relating to the care chosen by the participants for problematizing that day were presented.A subject chosen based on bibliographies and questions proposed by the facilitator was reflected upon.5 th ) Integration: an interval with a break for socializing.6 th ) Sharing and defining consensuses: presentation and discussion of the issues based in the literature, seeking a consensus.7 th ) Reviewing and redirecting conducts: space for evaluation of the meeting.
In the last two workshops, the 3 rd , 4 th and 6 th stages were removed and a new one was added, titled "listening, reflecting, dialoguing and acting".In these workshops, the proposal for care, organized and re-typed by the facilitators of the educational process, based in the consensuses established and reviewed by the group in the workshops, was presented and validated.
In the development of the educational practice, material resources were used: a voice recorder, a data-show, a computer, interactive material, Brazilian and international articles in translation, books, sheets of paper, pens and others.The records of the activities, perceptions on the participants and accounts recorded, after being transcribed, were organized by the facilitators.The results were organized in the light of Freire's assumptions and good practices.
The work followed the ethical principles stipulated in Resolution n. 196/96 of the National Health Council.The study was authorized by the institution where the practice took place and by the Ethics Committee of the linked institution, under N. 2194, FR: 454946/2011.The participants signed the terms of consent and anonymity was preserved, with participants being identified by the letter "N", followed by a corresponding number.

DEVELOPMENT OF THE EDUCATIONAL PROCESS
The proposal and the objectives were presented in the first workshop, and it was explained how the collective work and ethical aspects would be developed.The educational practice was made up of six workshops, with two undertaken in 2011, in October and November, and four in 2012 -two in March and two in April.They lasted for between two and three hours.They followed the stages already listed in the methodology, differing due to the themes and objectives established.The central themes were the care which is normally undertaken in the OC of the institution involved, in the NB's first hour of life, namely: drying, warming, skin-to-skin contact with the mother, clamping of the umbilical cord and care of the umbilical stump, breast-feeding, identification of the NB, administration of the credé method and konakion, checking of the vital signs and anthropometry, and the first bath.

The stage of embracement
In this stage, the environment and the materials were organized and the participants were received, affording a space for embracement, dialogue and participation.The material was provided beforehand and the invitation to participate was renewed prior to each workshop.

The stage of interacting and sensitizing
In this stage, a group dynamic was proposed related to the issue under discussion that day, being different in each workshop and described below.
The NB's bath was the theme of the first two workshops.In the first, the participants were requested to say one word on the NB's bath.They related this procedure to a time of returning to the intra-uterine life, concern, comfort, hygiene, warming and interaction.In the second, the same issue was explored based on the question: if you were the NB, in taking the first bath, how would you feel?Various aspects appeared as responses, including security, insecurity, coziness, tenderness, affection, attachment, and protection, these being important points which were taken up again when the issue was problematized.
In the third workshop, the themes listed were skin-to-skin contact, drying, warming, and breast-feeding.The operationalization of this stage consisted in the PowerPoint presentation of two presentations, one on the process of being born, and one on the mother with her NB in skin-to-skin contact.The interpretation of the presentations and the responses to the questions which follow dynamized the workshop: what do the images reveal?How should the care be in order to strengthen this relationship?The comments strengthen the protagonism of the parents and the energy which bonds parents and child: [...] it considers the mother, the father and the baby, protagonists of the birth.I really believe in this energy field.When it is just them, when there is no interference, they harmonize [...].This image shows how perfect it is when the baby is born.He is concentrated in that energy field, when he is born, where does he have to go?It is the baby who is removed, he does not for the same affective bond when there is this possibility (N-6).
[...] this energy, represented in the photograph, is so strong that it's impossible for us not to receive it.When you participate actively, you are very involved, you are regenerated and revitalized (N-2).
In the fourth workshop, the issues problematized were the clamping of the umbilical cord, the identification of the NB, the administration of the credé method and konakion.In order to work on the question of safety and confidence in the care, the technique of placing oneself in the care of another was used.The participant closed her eyes and let herself fall into the arms of another colleague.In this dynamic, the majority demonstrated fear of falling and being at the mercy of another.The feelings and sensations presented, translated into security and insecurity, depended on how the other person received them.This was extended to the NB and her care.
It's the way that we care.Because we know each other, and the baby doesn't.If you arrive in a place and have to do specific super-invasive procedures, depending on how the person holds you, whether they make you feel secure or not, you will yield to it or not.When we place ourselves in the role of the other, it is more difficult (N-6).
The way that you welcome begins with the environment which we have in the delivery room.The silence, the soft light in the delivery room for receiving this child (N-2).
The fifth and sixth workshops consisted of the presentation of the first and second part of the proposal of the care plan for the NB in the OC.In this stage, participants worked on the issue of "collective construction".In the fifth workshop, a jigsaw of a mother breast-feeding was collectively put together, with input from all the members in this.The experience was debated, focusing on the teamwork.In the sixth workshop, which dealt with reporting the good practices debated in the previous workshops, the collective construction of a story on the birth and attendance of the NB in the OC was suggested.One of the participants initiated the narrative, and created and told one part of the story, and the others continued the plot.Next, there was reflection on the content of the story, this construction serving to problematize the good practices.The story went like this: [...] Maria had a baby today in the OC called Peter.He was born in the morning in an environment with low light, and which was calm and tranquil.He was received by the neonatologist and placed on his mother [...].The obstetrician was asked to wait to let the umbilical cord stop pulsing before clamping it [...].While this was going on, the NB was dried and the wet area below the NB was removed and the NB was warmed with a blanket.[...] a little hat was placed on the baby's head, to stop him losing heat, and he could not stay with his mother [...].Then, after more or less 5 to 10 minutes, the cord was clamped, and the opportunity was given to the father to cut the cord.He wanted to cut it and cut the cord [...].At the same time, the clamp was passed to him, and the baby stayed there nice and snug on his mother's lap [...].There he stayed for 30 minutes, with his mother, and we observed the baby on the mother's lap and, involving the companion and the mother, in order to encourage the affective mother-baby bond and the father or other companion whom the mother chose.
[...] the mother was encouraged and guided to place the baby to breast-feed, this baby took the mother's breast with a good latch and good suction and stayed feeding for a good while.It was suggested that the baby should leave the mother's lap, but the nurse said no, at least 30 minutes.The facilitator added: '[.

..] seeing as how the routine changed, why do you now stipulate one hour of skin-to-skin contact, let's try for this baby to stay one hour in skin-to-skin contact with his mother' [...].
The use of games and group dynamics sensitized the professionals to reflect on and critically rethink their practices, which can create changes in the care provided in consonance with the literature.Educational games are methodological instruments capable of causing reflection, complex questions and generating opinions, collectively, based on the context of those involved, and of creating new social practices. 12

The stage of planning, validating and defining paths
In the third stage, the group was presented with the divergences and the problems related to the care which were indicated in the survey previously carried out, following the schedule agreed upon with the group for discussion of the care.In this step, the summary of the previous workshop was also presented, some initial corrections were made, and the consensuses described in the summary were validated.

Stage of problematizing the theme
The stage of "problematizing the theme" was considered the central activity, and occasion in which the participants, on most occasions divided in subgroups, reflected on and debated the care and the divergences in the practice and in the literature.
Normally, the divergences were presented which were related to the care chosen to be prob-lematized that day.The group added others which they judged to be important.They provided bibliographical references arising from a thorough survey of the care measures listed in the Brazilian and international databases, manuals, and books from the obstetric and neonatal area.Questions were also proposed on the issue, which were answered by the subgroups in order to facilitate the debate, and which sought to focus on who, how, where, when, and with what and why to undertake the care.
In the first workshop, the points debated were the most appropriate time for giving the NB the bath, the use or not of soap in the first bath, types of bath, and the bath and interaction with the parents.In the second workshop, the limitations for undertaking the bath were discussed, including the physical structure, the human and material resources, the bathing technique and the difficulties in undertaking it.This space was taken advantage of to show a video on the humanized Japanese bath and this procedure was debated.In the third workshop, the participants worked on the question of breast-feeding immediately after birth, the importance of skin-to-skin contact, and the time for doing this, and drying and warming the NB.In the fourth workshop, participants worked on the clamping of the cord at the right time, the care for the umbilical stump, and the administration of the credé method and the konakion (technique, product, and place of administration).The identification of the NB, vital signs and anthropometry were also debated jointly with the group in the fourth workshop.

The stage of sharing and defining consensuses
This stage consisted in presenting the subgroups and discussing the themes in the group.Based in the literature, the large group arrived at the consensuses described below.
In the 1 st and 2 nd workshops, consensuses were established regarding the NB's first bath.The participants, based in the literature, agreed that the bath should be given preferentially in the maternity ward.] In the third workshop, it was agreed that the NB, if born in good clinical conditions, should be dried delicately with warmed sheets and that a little hat should cover his scalp; that the mother and NB should be covered with a blanket to warm them, and that the NB should remain there in skin-to-skin contact with the mother for one hour to promote breast-feeding and the bond, any type of intervention being avoided in this period. 1,3,19n the 4 th workshop, consensuses were established regarding the technique for administering the credé method and konakion and clamping the cord.In relation to the technique for administering the credé method, it was agreed to undertake it preferentially at the end of the first hour, opting for the use of povidone-iodine 2.5%, with steps being defined for undertaking the procedure. 1,13,20egarding the administration of the konakion, it was established as a consensus to administer konakion intra-muscularly in the ventro-gluteal region (Hochstetter).2] Regarding the clamping, the decision was unanimous to wait for the cord to stop pulsing before clamping it. 1,3,13,19e stage of listening, reflecting, dialoguing and acting After the revealing, in the first four workshops, of the consensuses based in the practice and literature, the facilitators organized a proposal of care, which was presented, revised and validated by the group of nurses of the OC.It was 16 pages long and addressed the care, how, where, when and who should undertake it, with a scientific basis.It was agreed with the group that this collective production would later be presented, debated, added to and validated with the other professionals and other departments involved.

The stage of reviewing and redirecting conducts
In this period, an evaluation was made of the workshop and it was sought to redirect the actions of the following workshops.In the first two workshops, the group evaluated the works orally.The workshop was considered fruitful, an opportunity for reflecting, participating, exchanging information, suggesting the inclusion of the techniques at another opportunity, increasing satisfaction, coresponsibilization, and adherence to the proposal of this category, as shown by reports: [...] it is important to be able to discuss doubts, exchange opinions, raise the difficulties met in the work (N-4); [...] I liked it, it was assertive.It could include the nursing technicians.For them to be part of the construction is better than receiving the product ready-made (N-6).
In the third workshop, a question was used for assisting in the evaluation: if you were to have your child today, what would you want the health team to do?The responses indicated the good practices already debated.In addition, they suggested that the women should be empowered and that the professionals should rethink their practices.
[...] I wouldn't want them to cut the cord immediately, you have to wait for it to stop pulsing.You have to wait for the placenta to come out, because the placenta is of the baby, not of the mother [...].This is the time when the baby needs to stay with her mother, to adapt, to disconnect from her (N-6).
In the fourth and fifth workshops, in order to evaluate the group's degree of satisfaction, little faces were used which indicated satisfaction, indifference and dissatisfaction, with all participants indicating the satisfied faces.In the sixth workshop, a general, verbal and written evaluation was undertaken, in relation to all the workshops.The majority of the participants praised the initiative, highlighting the importance of the collective work based on the needs of the practice, the opportunity to update their knowledge and participate actively in the construction of a new proposal for caring for the NB with uniformity of conducts based in good practices, as in the accounts: Your effort such that all the nurses participated, for us jointly to be informed and to have uniformity of care for the NB, updated by the literature; for the people who are working to acquire knowledge, training the team, adapting the existing technique to the current literature, benefiting the mother, the father and the NB (N-8).
I learnt a fair bit.It was a very good opportunity and I'm happy because of this.The fact of us being in a university hospital [...]There is this commitment to be reviewing our practices, with all the theoretical basis.I think this is extremely important (N-2).
The written evaluation, done anonymously, emphasized that the educational practice was dynamic, and made it possible to debate practice undertaken in the OC, re-evaluate contents, and to review, discuss and update the care provided to the NBs, with a scientific basis.It was suggested to undertake the workshops routinely, providing opportunities to explore questions in depth which, in the day to day, it is not possible to discuss.Ev-erybody responded that the time, the duration and the strategies used were appropriate, there being no negative points.
I liked them a lot, because they were dynamic, and there was the construction of collective knowledge.There were no lectures, but there were relaxed times for updating and refresher training, with an objective to be achieved, and which brought much reflection and questioning about the routine praxis.The workshops were of great value for helping the nurses collectively to renew the assistance routines.Recently, this has been the most focussed promotion of knowledge which we have been given, in relation to concrete practice (anonymous); The workshops were dynamic, each issue was developed in a group.There was sufficient material, and most importantly, even though this subject is known and practiced, each meeting had something new, some change, avoiding tiredness.It was great [...] changes were made in the routine without much arguing (anonymous).

REFLECTING ON THE EXPERIENCE
The group educational practice consisted of a collective and creative dialogic process which allowed the subjects, based on their needs and previous knowledge, to seek paths for transforming the context in which they are inserted, creating and re-creating, in consonance with the actionreflection-action process proposed by Freire. 8The nurses feel motivated to participate, because they were able to contribute in solving problems which disquiet them in their working routine.They had the opportunity to reflect, to problematize the context, to give opinions, to be instrumentalized, to contribute knowledges and experiences with a view to finding solutions to overcome divergences found in the practice, in line with the literature.There was no transmission of knowledges, but the possibility was created for its construction and production, ratifying the thinking of Freire.
In the educational process, educator and those being educated become subjects of the process experienced, growing together in the exchange of knowledges and experiences.These persons co-intentioned to the context find themselves in a task in which both are subjects in the act not only of revealing it and problematizing it, and thus critically investigating it, but also in the act of re-creating the knowledge in it and produced based upon it. 8The critical and reflexive analysis which the cognizant subjects exercise on a significant dimension of the concrete reality, presented by them as a problem, allows them, through dialogicity and problematization, to construct responses and construct new knowledges 22 and to transform them in new possibilities for action. 8hus, education is the continuous path for developing the subjects' critical-reflexive capacity and for the collective construction of knowledges, based on the insertion in their context.Humans are beings of doing, of action and reflection, of praxis, responsible for transforming the world.For this, they need to articulate practice and theory.What to do is theory and practice, it is reflection and action. 22he educative process is not airtight, it is continuously being consolidated and being structured, and has neither beginning nor end.Education is a process of exchange, in which those who teach learn, and vice versa.It is in this search, with the others and in the practice of action-reflection-action, transcending the dimensions of space and time, that human beings give meaning to the everything, configuring their existence in the world. 22It is a constant exercise in favor of the production and development of autonomy, and entails decisions and responsibility with a view to being in a better way. 8n this perspective, the educational practice proposed supported the Brazilian Policy for Continuous Education, in a dialectic and progressivist perspective, in a significant learning, as it is based on the problems of the practice in the institution's daily life, on shared reflection and on the active participation of the professionals involved, on the problematization of the context; it strengthens the autonomy and professional competences, causes the production of knowledges and transformations in the work, and cries out for the continuity of the process. 23

FINAL CONSIDERATIONS
The collective educational practice was configured as a space for democratic and horizontal relationships which favored the socialization of knowledges, the strengthening of the competences of those involved, the negotiation and the partnerships.It was a space for creation and re-creation of knowledges, which allowed the transformation and innovation of the care for the NB, articulating the thinking, the knowing, and the doing in nursing.The exercising of dialogicity, reflection and problematization regarding their practices and the renewing implementation of the process of action, reflection and action, proposed by Freire, contributed to those involved becoming aware of the context, analyzing it critically and with greater flexibility, seeking to overcome problems which occur in the routine of the care for the newborn.
The educational practice constituted an enriching way for the nurses of the OC to exchange experiences, and problematize regarding the care offered based on their knowledge, and on scientific knowledge, enabling them to propose actions for transforming the care for the NB considered inappropriate into good practices, qualifying the care to the NB.
The study revealed the importance of involving the nurse and her team in works of this nature, because they raise awareness on the issue and introduce changes in a playful and harmonious way.They indicated the importance of involving other professionals of the OC, but are clear that this would be a complex task, given the significant number of professionals.They suggested replicating the educational practice with other categories.They considered that the nurse has a fundamental role in this process as facilitator, encouraging participation and strengthening the nursing team's potentials, so that they may make choices, and position themselves regarding the divergences in their routine of the care, review their practices and collectively build consensuses with a scientific basis.However, it is worth noting that there is still a trajectory to be traveled to implement some of these proposals, this being possible and viable to the extent that there is engagement and coorporation from the other health professionals and inpatient units in the maternity center.
It is recommended to undertake works with similar characteristics in other institutions, extending them to other health professionals, inpatient units and also to mothers and fathers, bringing new contributions in order for there to be more humanized care, centered on the well-being and safety of the NB, and on the interaction with her parents.