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On-line version ISSN 1982-0194
Acta paul. enferm. vol.22 no.6 São Paulo Nov./Dec. 2009
Meaning of the labor process: perspectives of nursing students*
Significado del trabajo de parto: perspectiva de los estudiantes de enfermería
Francisca Ana Martins CarvalhoI; Mônica Oliveira Batista OriáII; Ana Karina Bezerra PinheiroI; Lorena Barbosa XimenesI
INursing Ph.D., Associate Professor
at the Nursing Department Universidade Federal do Ceará - UFC Fortaleza
IINursing Ph.D., Post-Doc at University of Virginia-USA; Associate Professor at the Nursing Department, Universidade Federal do Ceará - UFC Fortaleza (CE), Brazil
INTRODUCTION: Education and training of
nurses on all aspects of the labor process promote quality care to women in
OBJECTIVE: To understand the meaning of the labor process by nursing students attending enrolled in the nursing course "Nursing Care Process III Woman."
METHOD: Symbolic Interactionism served as the theoretical framework for this qualitative study. Data collection consisted of participant observation and unstructured interviews.
RESULTS: Labor was perceived as a symbol of pain, anguish, fear, and anxiety. The meaning of the labor process was to witness the physical and emotional suffering of women in labor.
CONCLUSION: Nursing student experience in providing care during the labor process made the teaching-learning plan broader and suggested new perspectives to attend women in labor needs.
Keywords: Obstetrical nursing; Labor, Obstetric; Students, nursing; Teaching
INTRODUCCIÓN: Los fenómenos
que envuelven el trabajo de parto (TP) deben ser asistidos por los enfermeros;
por lo tanto, su formación es importante para proporcionar una asistencia
de calidad a la parturienta.
OBJETIVO: Comprender el significado del TP para el alumno de Enfermería que cursa la disciplina Enfermería en el Proceso de Cuidar III-Mujer.
MÉTODOS: Estudio de abordaje cualitativo, teniendo como marco teórico el Interaccionismo Simbólico. Para la recolección de datos, fueron usadas la observación participante y la entrevista abierta.
RESULTADOS: Los símbolos del TP que más aparecieron fueron dolor, angustia, miedo y ansiedad, y el significado elaborado por los alumnos fue que asistir a la mujer, en el TP, es presenciar el sufrimiento físico y emocional experimentado por la parturienta.
CONCLUSIÓN: La experiencia de los alumnos en la asistencia al TP hace que el proceso enseñanza-aprendizaje sea más amplio para el alumno, revelando significados que implican el establecimiento de una nueva perspectiva para la atención a las necesidades de la parturienta.
Descriptores: Enfermería obstétrica; Trabajo de parto; Estudiantes de enfermería; Enseñanza.
The millenary practice of supporting women during pregnancy, labor and their newborns until the end of the 18th century was performed basically by women, with the exception of some indigenous communities where husbands also helped(1). This practice passed from mothers to daughters and gave origin to midwives. With the coming of Obstetrics formally in the academy, in the middle of the 19th century, empirical care provided by women lost its space(2). In the 20th century, after the World War II, deliveries started to be carried out in hospitals to reduce maternal-children mortality.
In the 60's in Brazil retirement and pension institutes were united and the fund for Social Welfare was created by the federal government, which allowed the construction and expansion of the public and private hospital network(3).
The national health policy started to increasingly support hospital birth. In 1983, the Program for Total Women Health Care encompassed women's health in the pregnancy and postpartum period, high risk pregnancy prevention and also offered greater safety in hospital birth. This proposal aimed at integral health care establishing levels for referral and counter-referral(4).
In the 70's and 80's, pregnant women with a record in the existing pension system (INPS/INAMPS) received an admission slip to be cared for in an associated maternity, whereas women that were not associated used teaching or public philanthropic hospitals(4).
However, there were expressive advances in health, especially in 1980, with the movement of the Sanitary Reform and in 1988, with the creation of the Constitutional Letter. The Constitution states that health is "Everyone's Right and a Duty of the State", and, to reach this goal, the Unified National Health System SUS was created(5). One of the main advances was the institution of the prenatal care ensuring essential obstetric care to reduce the rate of maternal and perinatal morbidity and mortality(6).
According to the recommendations of the World Health Organization(7), in normal birth there must be a valid reason to intervene in the natural process. Care objective is for mothers and infants to be healthy, ensuring safety with the lowest level of intervention(7).
Through the directive of the Ministry of Health # 2,815/98, the procedure "delivery without complications" or normal delivery was included in the Table of the Hospital Information System of the Unified National Health System, performed by obstetric nurses ensuring their autonomy in care during delivery(5).
Childbirth can be seen as distressful by women since from the time they are admitted to the maternity they no longer have control of the situation, everything is unpredictable and unfamiliar. Women need health professionals to be close and understanding, especially nurses(8).
Based on this aspect, the authors are concerned with the education of new nurses that can assist women during labor and birth. The teaching-learning process goes through understanding of what it is, how to, and what to do to offer the best care for women in labor. Thus, the objective was for nurse students to understand labor and birth explained in the subject Nursing in the Care Process III Women's health.
Qualitative research, based on the perspective of Symbolic Interactionism, was chosen to understand the meaning of labor and birth for nursing students; this was done because we believed it is a guiding axis to understand the meaning of the study object.
The origin of Symbolic Interactionism is derived from Pragmatism, it started in the United States and England in the end of the 19th century. Several thinkers have contributed to its formation, the following are among them: Charles S. Peirce (1839-1914), William James (1842-1910), William Thomas (1863-1947), Jonh Dewey (1859-1952), Florian Znanniecki, Charles H. Cooley, George Herbert Mead (1863-1931), and Herbert Blumer (1900-1987).
In the theoretical-methodological design, Herbert Blumer coined the expression Symbolic Interactionism and described its perspective and method supported by the six radical images and three basic premises(9).
For the present study, the premises from Symbolic Interactionism were adjusted according to the study objective. Thus, we have considered that: students' actions in labor and birth are based on the meaning these processes have for them; the meanings of labor and birth derive from social interaction students establish with other people; these meanings are manipulated and modified according to an interpretative process used by students when they have to deal with labor and birth.
The study was carried out at the Center for Normal Delivery at the Maternity-School Assis Chateaubriand, Universidade Federal do Ceará (UFC), in this center, nursing obstetric practice is developed in the discipline Nursing in the Care Process III Women's Health, given in the 6th semester of the Nursing Undergraduation course at Universidade Federal do Ceará.
Data collection was carried out in two stages: the first was to observe nursing students' participation at UFC, during Obstetric Nursing practice in the mornings from Tuesday to Friday. Participative observation occurred through the direct participation of one of the researchers with the phenomena observed, to obtain information on the reality of students involved in the context of pre-labor and birth(10). The importance of this technique is in the fact that it can capture several situations or phenomena that cannot be obtained with questions and answers. The student directly observed through the reality talked about what was most unpredictable and evasive in real life(10).
The second stage was an open interview with 20 students taking part in the study based on the following guiding question: what is the meaning of labor and birth to you, after you have experienced it as a future nursing professional?
Furthermore, interviews were used to complement the understanding of the data obtained through observation. The interview is not only a data collection technique, but rather a social interaction between two people, the interviewer and the interviewee, to obtain information(11). Therefore, it is important to have a harmonic contact with informants(10).
Data have been examined according to content analysis(11), more specifically, according to thematic analysis. This was carried out in three phases: pre-analysis, exploration of the material, and treatment of the results as described by other scientific texts.
In the present study, legal and ethical principles of Resolution # 196/96, of the National Health Council have been observed(12), according to which, all research involving human beings must come with participants' written consent(13). To that end, the study was sent to the Ethics Research Committee at the Complexo Hospitalar da Universidade Federal do Ceará, where it was examined and approved. To ensure informants' anonymity, we have used fictitious names.
Twenty nursing students with ages ranging from 21 to 26 years old took part in the study, 18 were females. Among women, two were mothers, one had a normal delivery and the other had undergone a Cesarean section. Before they took the discipline, most these students(18) had already heard of labor and child birth, especially on TV (documentaries and films), through stories of mothers and friends that had undergone labor which were the most important source to know about the issue.
Therefore, students' previous experiences were essential to consider labor significant or not to for their teaching-learning process. Thus, in their statements, students expressed surprise about the physiologic condition of laboring women, because they did not know how labor developed.
When they were near women in labor, nursing students act according to the meaning labor has to them and this meaning is made from the interactions each student has with their world thorough their lives, that is, what they have heard from their mothers, relatives, and the media, among others. Thus, when they see women in labor, students always refer to the painful process that makes women suffer as we can see by the following statements.
Labor for some women takes long, making them suffer even more. Also because they want to see the baby's face, to see who it looks like. It is all the suffering, the pain, the contractions (DUDA).
It is very painful, very distressful for patients; they cry a lot, sweat, get restless and cannot relax (SUZY).
The meanings are formed by feelings, behaviors, and attitudes so that for the individuals of the study, the meaning of labor is directly connected with the painful process when laboring women express feelings of anguish, fear, pain, anxiety, incapacity, and even happiness. Supporting women in labor, in nursing students' point of view means physical pain characterized by uterine activity to dilate cervix.
Students that support laboring women describe pain as a complex and subjective phenomenon. It is filled with sensations and emotions resulting from their interactions with reality so that the meaning students give to labor is a dynamic and progressive phenomenon resulting from learning and from the context experienced.
That pain, everybody talks about that pain. I believe that women should not have to undergo all this suffering... Because on television, you see all that suffering, that thing, the faces, but I don't think it is as bad as people say (MÔNICA).
I believe many women, even ourselves, we have too many fantasies, we are apprehensive about labor. A difficult and painful time that will make women cry, feel pain, and we may have different reactions (NICE).
Triggering labor does not concern only one factor, but rather it is a multi-causal event. Students start to recognize physical suffering related to it because of dilation which is considered as a natural process, however, students fear complications that can occur during labor.
I understand that it is a normal, physiological process and that it will happen if there are one thousand people or not. It has to happen, it will evolve and if there is any problem, a solution will be looked for. Of course child birth occurs; it is a time of crises for women (REGINA).
For me it is a very special moment because there are doubts and questions to mothers. If their children will be normal, if they will have normal birth, or a Cesarean section (NICE).
The phenomenon of child birth involves concerns related to birth. Characterized by unpredictability, labor and child birth can be experienced with pain and possibility of risks and worsening of the physical state of mother and babies.
This can be corroborated by statements of students from the present study, because they believe both laboring women and themselves suffer emotionally when there is a threat to biological integrity, characterized by the irreversible state of women in a vulnerable position due to child birth. When they face an unknown and threatening situation, although they have theoretical knowledge, students demonstrate fear and anxiety because they are uncertain about what may happen (normal child birth, forceps or Cesarean section. Laboring women, either primiparous or multiparous, fear labor when it occurs, as demonstrated by the following statements.
Labor causes a lot of anxiety, especially when it is the first child, because you know....Even as a woman, you get curious about knowing how it is to have a child, but you do not know exactly how it is (MÔNICA).
Women are very fragile, they need attention, they feel anxious, they are in pain, it is a unique moment for them (REGINA).
Labor is a natural process, but, at the same time, it is not seen this way. Almost all women get scared, it was a very beautiful experience, I was very anxious (ANE).
Based on the statements of informants, we learned about the meaning of labor and child birth to students, and we realized their concern is directly related to child birth even though they have to support labor.
During care for women in labor, even though they considered supporting laboring women important, many times they were taken aback and scarred because they did not feel confident to perform any procedure. They had an elusive, apprehensive, and quiet behavior.
Through the convergence of symbols of labor and child birth for nursing students, it is clear that feelings, behaviors, and attitudes regarding labor and child birth have to do with pain, anguish, fear and anxiety, so that the meaning built by students is that supporting women in labor and child birth is to witness the physical and emotional pain experienced by laboring women.
Data presented here show that informants were mostly young females which characterizes the nursing undergraduate students whose knowledge on labor and child birth before taking the discipline Women's Health was limited to television (documentaries and movies), and to the stories of close people such as mothers and friends that had delivered a baby.
As researchers, we were able to live with students at the Centro de Parto Normal (Normal Child Birth Center), interacting with them during obstetric practice to understand better the meaning they give to labor and child birth.
Before child birth, women have to experience labor which is characterized by three stages (early, active and transition), starting with uterine activity and progressively continuing with cervix dilation and effacement, allowing for proper development of labor.
Labor is the most significant and dramatic stage for women and their families. It represents a set of physiological phenomenon occurring in a certain period with the purpose of dilating the cervix to prepare the birth canal for the passage of the fetus. These physiological phenomena are characterized by the presence of contractions with growing intensity that leads to cervical effacement, its progressive dilation, fetal presentation, and fetal expulsion(14).
Therefore, nursing students need to understand the clinical study of labor to be closer to this moment that is as important as child birth itself. Students, however, experience a paradox regarding their interest to know. At the same time they want to witness child birth, which is the miracle of life, they are not interested in observing the phenomenon that occurs to women during labor, which is a unique moment that is as significant as delivery.
Based on these premises(9), it is clear that nursing students act according to the meaning labor has to them(9), and this meaning was created based on students' interactions with their world of objects. Thus, everything they have heard from their mothers, relatives, communication media, etc was important to form this meaning. So the meaning of labor refers to a painful process that makes women suffer. Because meanings are formed by feelings, behaviors, and attitudes, students assimilate the feelings expressed by laboring women that go from anguish, fear, pain, anxiety, incapacity, and even happiness.
As the painful phenomenon of labor is complex, its interpretation should not be simplified. Pain in child birth resulted from several interactions with exciting and inhibiting features, and although they are similar to the mechanism of acute pain, there are other specific factors with an obstetric, neurophysiologic, psychological and sociological nature(15-16).
All human beings have a subjective idea of what the labor and child birth pain is. This is many times directly related to pain, suffering, and anguish. Labor pain is expected by women since childhood; labor is considered as something painful and dangerous, thus creating a type of conditioned reflex between the onset of labor and the beginning of pain(17).
Labor is a natural and physiologic process although it is frequently associated with a time of deep concern for those experiencing it, and for those around them, as it is considered a difficult and painful time. Regardless of the physiologic process, the way women and relatives face labor is related with the way they were socialized with the labor process(18).
Pain experienced in labor can worsen discomfort and increase adversities of their perception of the phenomenon occurring for their babies to be born. Pain is a complex experience with sensitive, emotional, and cognitive behaviors that interact among themselves and in the sociocultural environment(19).
Physiologically, labor occurs with release of oxytocin by the neurohypophysis through estrogen stimulation resulting from the following factors: suppression of progesterone secretion; increase in prostaglandins levels; calcium release by the sarcoplasmic reticulum; cervix and lower uterine segment compression and by the fetal part which is presented to maintain the ideal conditions for fetus and maternal well being(20).
The contraction during the process of labor is a syndrome where several factors get together triggering the triad awe, fear and pain, leading to anxiety, followed by women's physical and emotional discomfort(2).
Pain occurs due to activation of the nervous system, caused by fear that produces excessive tension and painful sensations in the uterus. Fear causes blood flow decrease in the uterus, increases discomfort, and lead to physical and emotional suffering. Pain during labor interferes not only in uterine contractility but also in the sociocultural and psychoaffective context of laboring women(21).
This emotional suffering may be triggered by the level of anxiety both for women that are experiencing labor and for nursing students experiencing the event. Therefore, both can be anxious, which can be constructive or destructive for satisfactory development of labor(22). This is unpredictable and, therefore, it may make laboring women feel anxious, insecure and frightened(18).
Anxiety is part of human existence and it is directly connected with the idea of future. It is feared and desired, and it is contradictory just as human nature, which may be emotionally manifested by anguish, leading to disorder in the expectation of impending danger.
However, through the educational approach, fear can be unconditioned and new reflexes can be associated with uterine contractions which would allow for a more active participation of women in labor and child birth. Although pain is a sensory phenomenon, fear and anxiety can worsen its intensity since it is a form of expression that is highly individual and emotional, varying according to the experience and history of laboring women.
During labor and child birth, associated anxiety and fear give dimension to pain. Excessive anxiety and fear increase pain and catecholamine secretion which leads to an increase in stimulus from the pelvis to the brain due to the decrease in blood flow and increase in muscle tension. As fear and anxiety increase, muscular tension is higher and the effectiveness of uterine contractions is reduced, multiplying discomfort, and starting the cycle of growing fear and anxiety(16).
We understand that the symbols for labor and child birth for nursing students converge to feelings and attitudes related to pain, anguish, fear and anxiety whose meaning is expressed in the fact that they see physical and emotional suffering experienced by laboring women.
At the end of the study, we could notice that students' view of their obstetric practice have changed due to the several situations of their routine (especially their interaction with laboring women) giving rise to new meanings and senses for labor and child birth.
Students interacting with women in labor, which means emotional and physical pain, reflect and conclude that they can support women in the whole process of parturition, despite the pain women feel in the dilation period and that they feel they are unable to act in response to laboring women's physical and emotional condition. In this moment, they understand that this stage (labor) is relevant for proper development of delivery.
After these experiences, the situation of teaching-learning is broader to students because it reveals meanings that lead to a new perspective to meet laboring women's needs, not only during child birth, but also during labor.
When they see and support child birth, it takes up a new meaning for students, since when they reflect and check and regroup according to the situation, they gear their decision making as how to act with women in labor.
Based on a favorable interaction, students feel open to share their joys, sadness, anguish, sensations, and pleasures from their experience in the Center of Normal Child Birth, which, according to them is unique and singular to their learning. Everything changes and is transformed when students see not only birth but also labor.
Support and care are part of the routine of nursing students. In this reality, learning strategies should be established so that humanized and holistic care meets the needs of patients. To be able to act, to take responsibility for laboring women, nursing students should know, see and assist labor.
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Article received 09/18/2008 approved on 03/16/2009 * Study developed from the Doctoral
Thesis defended at the Nursing Post-Graduation Program at the Nursing Department,
Universidade Federal do Ceará - UFC Fortaleza (CE), Brazil.
Article received 09/18/2008 approved on 03/16/2009
* Study developed from the Doctoral Thesis defended at the Nursing Post-Graduation Program at the Nursing Department, Universidade Federal do Ceará - UFC Fortaleza (CE), Brazil.