PERIPHERAL VENOPUNCTION AND ITS MAINTENANCE: SOCIAL REPRESENTATION BY WOMEN IN CESAREAN SECTION

ABSTRACT

Objective:

to identify and analyze the social representations and their dimensions about peripheral venous catheterization and its maintenance for anesthetic-surgical purposes in women undergoing cesarean section.

Method:

qualitative study of exploratory-descriptive type grounded by the Theory of Social Representations with the participation of 120 women and carried out in a public hospital in the state of Minas Gerais - Brazil, between 2019 and 2020. Evocations collected by interviews with application of the technique of free association of non-hierarchical words with prototypical analysis and by similarity in the EVOC and IRAMUTEQ software.

Results:

the present social representation addresses feelings in the behavioral dimension of stress, which are related to insecurity and fear of the pain of the needle, the surgical procedure, and the restriction of movements.

Conclusion:

the research contributes to a reflection on the need to resize nursing care before the difficulties faced by women in the triple experience of stress: cesarean section; venous catheterization; and the difficulty of performing postpartum care.

DESCRIPTORS:
Catheterization, Peripheral; Women; Cesarean Section; Nursing Care; Social Psychology

RESUMO

Objetivo:

identificar e analisar as representações sociais e suas dimensões sobre o cateterismo venoso periférico e sua manutenção para fins anestésico-cirúrgicos em mulheres submetidas à cesariana.

Método:

estudo qualitativo do tipo exploratório-descritivo alicerçado pela Teoria das Representações Sociais com a participação de 120 mulheres e realizada em um hospital público no estado de Minas Gerais - Brasil, entre 2019 e 2020. Evocações coletadas por entrevistas com aplicação da técnica de associação livre de palavras não hierarquizada com análise prototípica e por similitude nos softwares EVOC e IRAMUTEQ.

Resultados:

a presente representação social aborda sentimentos na dimensão comportamental de estresse, os quais são relacionados à insegurança e medo da dor da agulha, ao procedimento cirúrgico e à restrição de movimentos.

Conclusão:

a pesquisa contribui para uma reflexão da necessidade de redimensionamento da assistência de enfermagem ante as dificuldades enfrentadas pelas mulheres na tripla vivência de estresses: a cesárea; o cateterismo venoso; e à dificuldade de realizar os cuidados pós-parto.

DESCRITORES:
Cateterismo Periférico; Mulheres; Cesárea; Cuidados de Enfermagem; Psicologia Social

RESUMEN

Objetivo:

identificar y analizar las representaciones sociales y sus dimensiones sobre el cateterismo venoso periférico y su manejo con fines anestésico-quirúrgicos en mujeres sometidas a cesárea.

Método:

estudio cualitativo de tipo exploratorio-descriptivo fundamentado por la Teoría de las Representaciones Sociales con la participación de 120 mujeres y realizado en un hospital público del estado de Minas Gerais - Brasil, entre 2019 y 2020. Evocaciones recogidas mediante entrevistas con aplicación de la técnica de asociación libre de palabras no jerárquicas con análisis prototípico y por similitud en los programas informáticos EVOC e IRAMUTEQ.

Resultados:

la presente representación social aborda los sentimientos en la dimensión conductual del estrés, que están relacionados con la inseguridad y el miedo al dolor de la aguja, al procedimiento quirúrgico y a la restricción de movimientos.

Conclusión:

la investigación contribuye a la reflexión sobre la necesidad de redimensionar los cuidados de enfermería ante las dificultades enfrentadas por las mujeres en la triple experiencia de estrés: cesárea; cateterismo venoso; y la dificultad de realizar los cuidados posparto.

DESCRIPTORES:
Cateterismo Periférico; Mujeres; Cesárea; Atención de Enfermería; Psicología Social

HIGHLIGHTS

1. Need of re-dimensioning nursing care to favor mother-child bonding

2. The singularities of nursing care to women in cesarean section

3. Stress during cesarean section and venous catheterization

4. Difficulties in postpartum care due to the presence of a venous access

HIGHLIGHTS

1. Need of re-dimensioning nursing care to favor mother-child bonding

2. The singularities of nursing care to women in cesarean section

3. Stress during cesarean section and venous catheterization

4. Difficulties in postpartum care due to the presence of a venous access

INTRODUCTION

Peripheral venous catheterization (PVC) as an invasive procedure performed in the hospital environment for anesthetic-surgical purposes consists of cannulation of a peripheral vein by means of a flexible intravenous catheter inserted in a location compatible with the act and the surgical field used by the surgeon(s) when performing the procedure. It aims to provide a safe route for volume infusions of solutions, drugs, anesthetics, blood products, and hemodynamic stabilization of the anesthetized patient during the preoperative, trans operative, and postoperative periods^1-2, It can be installed by the nursing team, anesthesiologists, or residents on the ward, or even in the operating room during a cesarean section^3-4.

Regardless of the professional who installs, maintains, and removes the PVC, there is need for professional-patient interaction so that the procedure is safe for the patient, effective, less traumatic and culminates in a quality and humanized care. Hence the need for the professional who will perform the puncture to explain the procedure, to know the experiences of the user linked to the history of punctures, valuing, and combining their preferences to the therapeutic needs. Among the implicit therapeutic decisions are the choice of the site to be punctured and the material to be used, requiring technical rigor and routine assessment of the insertion site and adjacent areas, to maximize its durability and prevent the installation of vascular trauma⁵.

Therefore, social representations enable the knowledge of experiences and experiences of a socially constituted group about a given object, allowing scientific content to be apprehended by lay people from group constructions influenced by historical and social determinants, and thus, the meanings are attributed and shared by the group in everyday life^6-7.

Thus, women hospitalized and undergoing PCV during a cesarean section, when inserted into the same context, can be characterized as a social group capable of representing the reality lived and experienced with the PCV procedure.

The present investigation is justified by the fact that PCV is an essential procedure to enable the administration of drugs during the anesthetic-surgical procedure, and in the postpartum period, to ensure rapid care through infusion of volumes of solutions in situations of surgical-anesthetic intercurrences, enabling hemodynamic stabilization, since it is an experience experienced by women undergoing cesarean section that can impact on baby care and also on their social representation.

Considering the above, the object of the research was: social representations about the PCV for anesthetic-surgical purposes in women undergoing cesarean section, and the objectives were: to identify and analyze social representations and their dimensions about the PCV and its maintenance for anesthetic-surgical purposes in women undergoing cesarean section.

METHOD

Qualitative exploratory-descriptive research based on the theoretical and methodological framework of the Theory of Social Representations (TSR) of which the structural approach⁸ made it possible to identify the perceptions, experiences and lived experiences of women undergoing peripheral venous catheterization for cesarean section during hospitalization. It was developed in a gynecological and obstetric surgery unit of a public hospital affiliated with the Brazilian Unified Health System (SUS- in Portuguese) in a city of Minas Gerais. The research was conducted in the period from March 2019 to January 2021.

Inclusion criteria were older than 18 years of age who had their blood vessel punctured for anesthetic-surgical purposes in a cesarean section. Exclusion criteria were women with altered level of consciousness and/or coherence or who postponed their participation for more than three attempts at different times. There were 12 losses due to: postponement with postponement for more than three occasions (8); refusal alleging pain complaint (4), totaling 120 participants.

The recruitment of potential participants occurred by convenience, in person and individually, at the bedside in the hospitalization sector after cesarean section in the presence of the companion. At the time, they were informed about the object of research, purpose, risks, and potential benefits with acquiescence expressed by signing the post-informed informed consent form (ICF). Convenience sample whose sample size met the recommendations of the literature (n>100) to justify the completion of data collection in studies on the structural approach of TSR⁹.

Data collection, which occurred through individual bedside interviews, guided by the previously trained researcher, a graduate student in nursing and who had no previous relationship with the participant, was composed of 1) structural approach to SRT; and 2) sociodemographic characterization of the participants. Data were collected from August 2019 to March 2020 and averaged 30 minutes in duration, being recorded at the time of collection by the researcher using the Open Data KIT (ODK 2.0) software, a technology on Android platform that manages the electronic sending of the collected information to a server (cloud), which dispenses with manual consolidation, minimizing any typing biases. The data collected was archived by the main researcher.

The first step was the structural approach of TSR, which consisted of applying the free word association technique (TALP- in Portuguese), in which each participant mentioned the first five words that came to mind when the inducer terms “catch vein” and “keep vein” were mentioned, and the evoked cognemes were recorded in the ODK in the order of evocation. It is worth mentioning that data collection in the structural approach of TRS aims to identify collective contents spontaneously and without analytical interference. In this case, the inducer term is an expression that refers to the object of representation. Thus, the content was not shared with the participants for review due to the spontaneity of being an essential characteristic of the data collection technique and the theoretical framework adopted.

Only in the second stage were the data of sociodemographic characterization of the participants collected so as not to interfere in the evocations. The sociodemographic characterization was consolidated in the Statistical Package for the Social Sciences (SPSS) software and analyzed according to descriptive statistics (frequency, percentage, mean, minimum and maximum).

In the structural approach, the evoked cognemes were transcribed into Excel and Word for Windows, for the elaboration of the dictionary of equivalent terms and subsequent prototypical and lexicographical analysis operated in the Software Ensemble de Programmes Permettant L’Analyse des Evocations (EVOC) that provided the four-box table with the ordering of the evoked cognemes according to the Law of Zipf¹⁰ based on the criteria of frequency and average order of evocation whose allocation was structured in four quadrants, allowing subsequent deductive analysis of the representational and hierarchical contents of the research object. Thus, the following parameters were standardized: Minimum frequency 16; average 46 and Average Order of Evocation (AOE) 2.9. For the inducer terms take and keep vein 565 and 567 cognemes were evoked, being 30 and 39 distinct, which is equivalent to 97.5% and 89.2% of the corpus respectively.

The psychosocial paradigm of the structural approach of TSR with prototypical analysis of the cognemes evoked by the participants is justified by portraying the contents agreed upon by the social group based on their relevance for the identification of the social representation^6-7, these cognemes are placed in the Upper Left Quadrant (ULQ), the probable central nucleus, in addition to the cognemes with higher frequency of evocation and lower rang, which shows the SR to be stable, resistant to change, collective, consensual, and independent of the immediate context. In the Lower Left Quadrant (LLQ), the contrast area, cognemes with low frequency and rang were allocated, in other words, consensual for subgroups.

On the other hand, the elements allocated in the peripheral system are liable to adapt to reality when there is a rapid change in the context experienced, aiming at protecting the central core that does not undergo changes. They originate from individual experiences and histories, which enables them to be transformed, dynamic, flexible, and sustain contradictions^11-12. The peripheral cognemes are allocated in the Upper Right Quadrant (URQ), called the first periphery, for being mentioned with higher frequencies and rang, portraying contents mentioned in the last positions, and in the Lower Right Quadrant (LRQ), also known as the second periphery, characterized by low frequency cognemes and rang, which portray personal experiences^7,11-12.

To validate, ensure the credibility of the contents obtained in the prototypical analysis and reaffirm the importance of the representative cognemes, the similarity test was performed to identify the co-occurrences, (calculation obtained by the proximity index between the evoked cognemes with variability from zero to one) in the IRAMUTEQ program, version 0.7, alpha 2, presenting the affinity of the contents evoked regarding the puncture and maintenance of the PVC for the surgical anesthetic procedure during cesarean section by graphs according to the Fruchterman-Reinglod community tree and focus^13-14.

The representation of the similarity test was made in the Iramuteq program, version 0.7 alpha 2, culminating in the representation of the tree in community and focus according to Fruchterman-Reinglod, which made it possible to obtain a graph in which evoked cognemes were grouped according to the affinity of their evoked contents regarding peripheral venous catheterization for cesarean section anesthetic procedures¹⁴.

The research was approved by the Research Ethics Committee (REC) of the Federal University of Juiz de Fora under opinion number 3,198,431 on 03/14/2019. The anonymity and confidentiality of the participants were preserved with the use of alpha numeric identification in the instrument at the time of data collection and subsequent data analysis, represented by the acronyms GC followed by the number 9 and subsequent order of data collection (GC9001; GC9002).

RESULTS

The characterization of women undergoing peripheral venous catheterization for anesthetic-surgical purposes for cesarean section was characterized with a mean of 28.14 years and variability of 18 to 47 years; mean of 11.36 years of schooling, white, married; mean of 1.91 children, middle level occupation, income of one minimum wage, and catholic. The characterization of the participants is presented in Table 1.

Table 1
Characterization of the participants according to age, skin color, education, marital status, number of children, education, income, and religious practices (n = 120). Juiz de Fora, MG, Brazil, 2020

Variables	n	%	Average ± SD (min-max)	Variables	n	%
Age			28.14 ± 6.472 (18-47)	Marital Status
18 I---20	11	6.7		Married	50	41.7
20 I---30	66	55.1		Single	41	34.2
30 I---40	40	38.2		Stable Union	28	23.3
41 I---47	3	2.5		Separated	1	0.8
Study time				Skin Color
4 I---9 years	20	16.7	11.36±2.566 (4-18)	White	62	51.7
9 I---11years	41	15		Black	39	32.5
11 I---18years	59	68.3		Brown	18	15
No. of Children				Yellow	1	0.8
0 children	1	0.8	1.91 ± 0.961 (0-4)	Occupation
1 child	50	42.5		Household	19	15.8
2 children	36	30		Elementary level	27	22.5
3 children	25	20.8		Middle level	64	53.3
4 children	8	6.7		Upper level	10	8.3
Income (salaries)				Religious Practice
0	37	30.8	1.0±0.748 (0-5)	Catholic	51	42.5
1 I---2	62	51.7		Evangelical	37	38.8
2 I---5	21	17.5		Spiritism	3	2.5
				Agnostic	7	5.8
				Other	22	18.3

• Source: authors (2020).

The characterization regarding women’s previous experience in relation to the birth route was the prevalence of cesarean deliveries with a mean of 1.62 childbirths with a history of abortion as presented in Table 2.

Table 2
Characterization of participants’ previous experiences regarding birth and abortion route (n = 120). Juiz de Fora, MG, Brazil, 2020

Variables	n	%	Average ± DP (min-max)
Normal childbirth
0	98	81.7	0.31 ± 0.700 (0-4)
1	13	10.8
2	5	4.2
≥3	3	2.5
Previous Cesarean sections
0	5	4.2	1.62 ± 0.899 (0-4)
1	59	49.2
2	32	26.7
≥3	23	29.2
Did not answer	1	0.8
Abortions
0	80	66.7	0.24 ± 0.595 (0-3)
1	13	10.8
2	04	3.3
3	01	0.8
4	17	14.2
≥5	5	4.2

• Source: authors (2020).

Women presented feelings associated with stress, insecurity and fear of pain related to the act of paying for a vein for surgery, and the act of maintaining a venous access in this group is representative because it makes postpartum care more difficult due to the restriction of movement. Below are the four-house charts referring to the inducer term “taking vein” and “keeping vein” for surgical-anesthetic purposes for performing cesarean section and respective similarity tests (Figure A and B).

Figure A
Four-box tables for the inducer term “grab vein” for cesarean section anesthetic-surgical procedure and respective similarity tests. Juiz de Fora, MG, Brazil 2021.

In the similarity tree, we identified the confirmation of cognemes as possible centrality in the SR due to their strength and the number of links with the other evoked terms.

Figure B
Four-box tables for the inducer term “keeping vein” for cesarean section anesthetic-surgical procedure and respective similarity tests. Juiz de Fora, MG, Brazil 2021.

The probable core of the social representation of PVC puncture in participants undergoing cesarean section addresses negative feelings described as “pain-comfort” and “fear-panic” that demonstrated the behavioral/attitudinal dimension of this Social Representation (SR). Women presented these feelings associated with stress, insecurity and fear of pain related to the use of the needle to pierce their skin and the surgical procedure, demonstrating, in contrast, the need for its realization.

In the contrast area, the cognemes “necessary-to-leave” and “ medicine-serum-fasting” were identified, demonstrating the evaluative and objective dimensions of SR, respectively. Thus, although the participants showed a negative sentimental view of the procedure, they reported the value of performing it to obtain improvement together with the need for medication administration. In the first periphery, the cognemes “nervous” and “hurts-stresses” emerged, expressing the behavioral/attitudinal dimension, demonstrating again negative feelings before the need to perform the procedure.

In the second periphery of the four boxes, we identified the cognemes “needle”; “stick-puncture”; “blood”; in the objective dimension and “do not-find-vein” and “professional skill” in the evaluative dimension. These terms express the individuality of the lives and experiences of the participants who demonstrated the importance of the procedure involving objects that negatively impact their perception as the use of the needle and the presence of blood added to the behavior of the professional practice that also contributes to the representation of negative feelings.

In the evocations for the inducer term “maintain vein”, the cognemes “limits-movement” and “same-position” emerged in the possible central nucleus, expressing the behavioral dimension of SR. The act of maintaining a venous access in this group makes postpartum care more difficult due to the restriction of movement being representative for women.

In the contrast area, the cognemes “evaluate-location” and “lose-vein-other-hole” emerged, demonstrating the behavioral dimension. Given the specificity of the postpartum moment of these women and the need for movement for self-care and with their newborn, the concern of these women to maintain venous access emerged as they reported the importance of monitoring the site of venous access with fear of the need for a new venipuncture.

In the first periphery was found the cogneme “adhesive-healing tape” with the highest frequency of evocation in the framework of four houses that leads us to the possibility of centrality in the SR. This term caused the concern of women with the installation of the cover of the venous access to avoid its accidental loss in view of the need for movement to perform the daily care of their baby. The cogneme “stopped-stretched” illustrates the concern with the loss of access to the point of restricting movement, to maintain venous access during hospitalization before the need for venous medication and clinical stabilization, demonstrating the behavioral dimension of the SR.

Finally, the second periphery identifies cognemes that expressed the individuality of the experiences of these women at other times or by reports from other subjects. These cognemes were present in the SR of other contexts and subjects, and influenced the SR of some participants, without becoming representative for the majority. The cognemes identified by these subjects were: “fix-immobilize”; “care-don’t pull-tract”; “calm”; “serum-medication”; “place-(in)adequate” and “skill-professional”.

DISCUSSION

According to the results on occupation and marital status, the data are consistent with the literature, in other words, women who have cesarean sections for the childbirth of their babies have an average level of education and marital stability¹⁵. The characterization of the experiences of the women investigated showed a prevalence of cesarean section instead of normal delivery, considering the previous experiences of the women participating in the research.

In Brazil, the cultural profile of childbirths is prevalently cesarean due to maternal requests and unclear medical indications based on scientific evidence. The request for cesarean section occurs because of reports of fear of obstetric labor, compromised vaginal anatomy and sexual life, insecurity of the technology used, underestimation of the risks of cesarean section, and unknowing of the benefits of normal delivery¹⁶.

According to the World Health Organization, cesarean rates are around 56.3%, but this indication should correspond to 15% of childbirths, but in Brazil, records show it is the second country with the highest cesarean rates in the world¹⁷. This leads us to reflect on the knowledge, values, and representations that Brazilian women have about the type of childbirth to be performed, pointing culture, experiences, and previous experiences of their own, acquaintances and professional conduct as determinants of their choices^18-19.

The presence of pain and fear related to peripheral catheterization in the step of introducing the catheter into the blood vessel is a social representation present in other contexts and social actors, such as hospitalized adults^20-21 and women¹. PVC in women undergoing cesarean section surgical procedure shows that the negative feelings come from a double burden of stressors because they are submitted to two invasive procedures of which they have little or no knowledge, besides being exposed to the practice of knowledge and success regarding the professional’s ability that is put in check^1,20.

In contradiction, when the use of veins is intended for the use of injectable drugs, the procedure is represented by positive feelings, contrary to the SR found here, being justified by self-satisfaction, or helping others²². The justification for accepting PVC is pointed out in other studies by the need to administer intravenous medications, to obtain clinical improvement and speed in relation to therapy²⁰.

The maintenance of venous access makes movements and self-care difficult, besides meaning the restriction of mobility of the punctured limb for fear of losing the access and being subjected to a new procedure, which will bring new suffering. In another context and with other social actors, such as adults during hospitalization, these data are corroborated²¹.

By analyzing the tree of similitude, it is understood that the cogneme “adhesive-staple-healing” assumes possible centrality in the SR, and its occurrence can be analyzed due to the high frequency of evocation expressed in the four boxes and the strength and number of links with the other cognemes expressed in the tree of similitude. Thus, the cogneme “tape-healing” assumes possible centrality in the SR of the maintenance of venous access by women undergoing cesarean section. It is worth noting that this cogneme has a high binding force with the probable central nucleus expressed in the four boxes.

The concern with the proper attachment of the PVC occurs due to the need for movement to care for her newborn, which increases the risk of accidental loss of access. Among the difficulties recorded in 1,608 medical records of a specialized service in which breastfeeding is practiced by 72.6% of the users, a statistically significant association was identified between breastfeeding and the difficulties mentioned by the mothers. Among the situations mentioned was the mother-child positioning²³.

The permanence of an intravascular catheter in the immediate puerperium period can be considered an uncomfortable and limiting situation for the mother-child interaction to the point of hindering the accommodation of the newborn in the maternal lap and its positioning in the nipple. This can occur mainly when the catheter insertion is in the dominant arm and positioned in the hand or forearm. There are recommendations for the PVC to be installed in regions far from joints and, preferably, in a non-dominant limb, which contributes to the increase of time for the maintenance of patent access and facilitates the activities of daily living, such as hygiene, feeding, sleep, among others^24-25.

Although the use of adhesive tape was mentioned by the participants, there is a recommendation for the use of transparent, sterile, and semi-permeable dressing because it allows better visualization and follow-up of possible vascular traumas resulting from the presence of the catheter at the puncture site and adjacent areas when compared to the excessive, unnecessary, and contraindicated use of adhesive tape^24-25.

The previous experiences and experiences of people interfere in the way they face a reality, which can be of personal, family, or acquaintance origin, or through knowledge coming from other professionals, which will influence the individual of each subject, and does not become a social representation of the object for the current context.

One of the limitations of this research is the fact that it was conducted in a single hospital with women who underwent cesarean section, which makes it impossible to transpose the results to other contexts and people, because social representations are influenced by the context and experiences of collective groups. Moreover, one should consider the reason for the procedure, the patient’s age, previous experiences and experiences, and culture as unique aspects, suggesting its replication in other realities.

FINAL CONSIDERATIONS

The social representation of peripheral venous catheterization addresses negative feelings of pain, discomfort, fear, and panic that demonstrate its behavioral/attitudinal dimension intensified by the moment of surgery and insecurity experienced by women during the cesarean section; and the representation of keeping the vein also demonstrates the behavioral dimension expressed by the difficulty of performing postpartum care due to the restriction of movement.

This research contributes to a reflection, and points to the need to develop new investigations about the indispensability of resizing nursing care related to the process of peripheral venipuncture in women undergoing cesarean section, when considering the difficulties faced to provide postpartum care due to the presence of a PVC in the limb, coupled with the fear of its loss, requiring a new puncture and, also, the double stress faced, in other words, venous catheterization and performing a surgery with the birth of her baby.

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• *
  Article extracted from the master’s/PhD thesis “CARGA DE TRABALHO DA EQUIPE DE ENFERMAGEM E RASTREADORES DE EVENTOS ADVERSOS NA ENFERMAGEM PEDIATRICA”, HOSPITAL UNIVERSITARIO JULIO MULLER, UNIVERSIDADE FEDERAL DE MATO GROSSO, CUIABA, MT, BRASIL, 2021.

Edited by

Associate editor:

Dra. Tatiane Trigueiro

Publication Dates

• Publication in this collection
  24 Mar 2023
• Date of issue
  2023

History

• Received
  13 Aug 2021
• Accepted
  22 Aug 2022