OBSTETRICAL PRACTICE BY NURSES IN INSTIUTIONAL CHILDBIRTH : A POSSIBILITY FOR EMANCIPATORY KNOWLEDGE

This was a qualitative research project with the objective to analyze the meanings attributed by nurses to changes in their obstetrical practice, using the method “production of meanings in the everyday – discursive practices,” as proposed by Mary Spink. Data was collected through semi-structured, individual interviews with 16 obstetrical nurses in public maternity wards in Rio de Janeiro, Brazil. The interviews were analyzed with the concepts “crossing boundaries” and “constellations of power,” by Boaventura Santos. The meanings attributed by the nurses to the obstetrical practices verified a transformation process in the field of obstetrical knowledge, and practices in the perspective of demedicalization. The frontier, as a place of paradigmatic transition to new practices, emerges in emancipatory relationships with the women users of the service. We conclude that experimentation with new practices involves overcoming known limits to find autonomy, configuring a knowledge and practice with emancipatory possibilities. In this direction, crossings come from the boldness to seek and experiment the new, transgress the limit, and make use of open spaces in the constellation of powers. DESCRIPTORS: Woman’s health. Obstetrical nursing. Humanizing delivery. LA PRÁCTICA OBSTÉTRICA DE LA ENFERMERA EN EL PARTO INSTITUCIONALIZADO: UNA POSIBILIDAD DE CONOCIMIENTO EMANCIPATORIO RESUMEN: Investigación cualitativa tuvo como objetivo analizar los sentidos atribuidos por las enfermeras en los cambios de su práctica obstétrica utilizando el método de producción de sentidos diariamente, propuesto por Mary Spink. Los datos fueron recolectados por medio de entrevista individual, semi-estructurada, a 16 enfermeras obstétricas en maternidades públicas Rio de Janeiro, Brasil. Se analizaron los conceptos de trayecto de fronteras y constelaciones de poder de Boaventura Santos. Los sentidos atribuidos a las prácticas obstétricas evidenciaron una transformación en proceso del conocimiento obstétrico y sus prácticas en la perspectiva de la desmedicalización. La frontera, lugar de transición paradigmática de nuevas prácticas, donde surgen las relaciones emancipadoras con las mujeres. Concluimos que las nuevas prácticas involucran la superación de límites conocidos para encontrar autonomía. Las trayectorias ocurren por la audacia de buscar y experimentar lo nuevo, de transgredir el límite, y aprovechar los espacios abiertos en la constelación de poder. DESCRIPTORES: Salud de la mujer. Enfermería obstetricia. Humanización del parto. 763


INTRODUCTION
In Rio de Janeiro in 1988, the introduction of the obstetrical nurse in hospital childbirth care in one of the maternity wards of the Municipal Health Department provoked a process of expansion of this care into other maternity wards, in a movement of advance and retreat that had implications on professional knowledge and practice.The participation of this nurse has been marked by changes that accompany the proposal of transformation of practices in vaginal birth care, to a less-interventionist healthcare model in the maternity wards where she works.The excessively medicalized model of childbirth medical care is criticized worldwide, which culminated in the systematic evaluation of obstetrical practices.These studies generated a set of directives and recommendations, based on the scientific evidence that the World Health Organization (WHO) has been adopting during the last few decades. 1 In light of these recommendations, vaginal birth is considered a physiological event that needs support, evaluation and vigilance.Evidence shows that intervention in this process should have a valid justification. 2 Indicators such as prenatal care and access to hospital birth improved; however, rates of maternal mortality remain stable and high.4] The model of humanization of childbirth and labor seeks the formation of a new healthcare arrangement, oriented by safety and efficacy of procedures for the greater promotion of women's right, through a new culture of healthcare and communication those involved.
In the 1990s in the municipality of Rio de Janeiro, there was an expansion of the experience of putting into practice the Policy for Humanizing Labor and Childbirth.This established the hierarchy of childbirth care, giving the obstetrical nurse direct care of low-risk births. 5In Rio de Janeiro, this became a public policy experienced in a tense environment, marked by the dispute over space among obstetrical professionals.In the search for ways to overcome this resistance, the obstetrical nurse, as a strategic agent in the implementation of practices of the humanized model in the hospital environment, used strategies that made her/his insertion into the scenario possible.The obstetrical nurses developed a project, investing in training and assigining credentials to the nurses working in the institution, discussion and dissemination of the results of the care implemented, and strategies for amplification of contact with the pregnant women and their families in prenatal care, sharing and constructing knowledge in partnership with the healthcare users. 6he obstetrical nurses have shown a willingness to develop specific abilities, in a womancentered and demedicalized model, putting into practice actions of humanization and demedicalization of childbirth in the sphere of management, teaching and care. 7Obstetrical professionals face the challenge of technical adaptation of the model, through investment in methods of comfort and care, and the proper use of available and desired technological advances.The research had the objective to analyze and discuss the meanings attributed by obstetrical nurses to their practice of childbirth care.

METHODOLOGY AND THEORETICAL CONCEPTS
Qualitative and social research made it possible to be immersed in the way of thinking discussed by Spink, seeking the production of everyday meanings through discursive practices, which determined the choice of the methodological framework, in consonance with the problematic and object of this study. 9he production of everyday meanings is a theoretical-methodological approach for analysis of discursive practices in qualitative research. 10eaning is considered a social, collective and interactive construct, where the dynamic of social relationships constructs the language that comprehends the phenomena experienced in the everyday.The production of meaning is understood as a socio-linguistic phenomenon, since the use of language provides support to the social practices that generate meaning.This research sought to understand the discursive practices that occur in the everyday as narratives, reasoning, conversations, as well as the repertoire used in these discursive practices.
Data collection occurred from August to November 2010, with 16 study participants who were obstetrical nurses working in the six maternity wards selected, who were invited to the production of meanings, using the technique of individual, semi-structured interviews.Inclusion criteria was at least ten years working in hospital childbirth care, characterizing experiences in the field.In order to highlight the comprehension that the participants reported in their statements, we used the concepts of Spink 9 to organize the interviews and obtain the analytical categories. 9he structure of the interview script shows that the questions sought to highlight the obstetrical practice of the nurse in childbirth care, in the context of the life and profession into which s/he is inserted, showing the motives for choosing the area of work and how s/he attributes meanings to the trajectory of their obstetrical practice.This strategy permitted the understanding of the dynamic of discursive exchanges, and analysis of the themes that were prioritized to attain the research objectives, in addition to giving a group vision. 9n this interpretative movement, the theoretical axes of analysis emerged, based on the concepts of the sociologist Boaventura Santos 11 called "crossing boundaries" and "constellations of power."This author analyzes social structures, considering western modernity to be a paradigm founded on regulation tension and social emancipation.In this perspective there is an interval in contemporary societies and cultures.This interval has a movement that is situated in the transition between the dominant paradigm and an emergent paradigm; we are situated in a period of paradigmatic transition on the path to another paradigm. 11he paradigmatic transition is presented into two principal dimensions: the epistemological and the societal.The two transitions are autonomous yet related, as alternative forms of knowledge generate alternative social practices.The grand mediator between knowledge and practice is the subjectivity that unites the two transitions.The transformative action proposed in the paradigmatic transition produces social relationships where challenges need to be overcome, and, by intermixing into this space the concepts of Santos, of constellations of power and crossing of boundaries, helped us to produce the analysis of subjectivities that emerged from the data which, as the author points out to us, are the point of union between the two dimensions of this epistemological and societal transition. 11n the practices analyzed, there is a constellation of power in the institutional spaces that function autonomously, but there are intersections influencing the reality within large structures such as a the Unified Health System, its national and local management, institutions of professional training, in their dimensions of teaching, extension and research, constituting unstable relationships that one minute encourage the participation of institutional agents, and the next minute retreat from the offer of possibilities.
The same author states, "no paradigmatic transformation will be possible without the paradigmatic transformation of subjectivity". 11:333 Santos presents us with maps of the paradigmatic transition called emancipations.He continues, saying that the emerging subjectivity has the pleasure of living on the boundary, which emerges as a privileged form of sociability.
The research site was the David Capistrano Filho Birth Center and five public maternity hospitals in the municipality of Rio de Janeiro.The research was approved by the Ethics Committee of the Municipal Department of Health and Civil Defense of Rio de Janeiro, through opinion number 192 A, on August 10, 2010. 12

RESULTS AND DISCUSSION
Of the 16 obstetrical nurses who participated in the study, 13 were women and three were men, with ages ranging from 38 to 57 years.When they spoke about their professional training, they informed that they were interested to work in obstetrics since graduation, yet were only able to work in childbirth care about twelve years after their basic training, pointing to lack of opportunity and not of interest to work in obstetrics.
Among the actions proposed to break the interventionist logic of vaginal birth care, they present strategies such as intra-or extra-hospital change of environment, from Obstetric Centers to Vaginal Birth Centers, in addition to community Birth Centers.In these environments, there is a production of knowledge centered on the woman as protagonist, transforming the relationships between professionals and users.The insertion of the obstetrical nurses into the traditional scenarios of the maternity wards provoked an imbalance in the established order.We recognize these spaces as representing paradigmatic transition, and consider the traditional obstetrical center to be where the regulation-knowledge prevails, which unfolds in a care model governed by medicalization.

The boundary: establishing relationships with stagnant forms of knowledge and practices; crossings between theory and practice
The meanings attributed by the nurses, in discussion about their everyday practices in childbirth care, draw the boundary space.It is the place of the paradigmatic transition, from where emerge the opportunities of emancipatory practices.This is a tense movement, as to invest against the instituted order, where external and internal limits, mediated by knowledge, appear in the relationships between professionals and with the clientele, which need to be transcended in the direction of an emergent model.
One of the meanings presented by the study participants was the confrontation between the knowledge acquired in the biomedical model and the experiences from everyday practice, verifying that changes in care of women in childbirth are necessary: we change every day.I now believe that they are small details, because I found the main idea some time ago.In the beginning when we started, we were really influenced by the biomedical model.We still did episiotomy; honestly, I still had not been sensitized sufficiently to begin this practice without episiotomy.As time went by, I began to perceive that there was no need for it, and this practice was allied to all of the information that we were receiving.I wanted to participate, to absorb all of that new information, and this, combined with practice, was a really transforming agent (E3).
The epistemological rupture, in post-modern science, is an important leap from scientific knowledge to common sense.Knowledge learned through multiple sources, and transmitted to many others, without distinctions. 13They can come to be a new common sense, with more meaning, albeit less common. 14e sought to explore the researched birth scenarios as spaces of boundary, to reflect the emerging subjectivities provoked by this context, with the purpose of finding the meanings attributed by the nurses to their practice, and the potential for changes, as shown in the expressions below: [...] today I consider myself a transformed professional.In the beginning, I learned a lot but had no idea.I didn't like what I saw in practice, and tried to find people and knowledge that was different from what I saw.Even when I was in maternity ward X, with all of the talk about humanization, we still saw a lot of stuff, and parallel to this, we had the urge to do something different.We were a group with a very different vision, and we began to seek different proposals for childbirth, for assisting it, etc.I saw one woman who was violated in that method, and I wanted something different; I did not want to do the same things.In a way, that [experience] also violated me.I did not want to see any more of those cervix reductions, I did not want to see any more Kristeller maneuvers, nor did I want to do them (E4).
The movement of crossing over toward a less interventionist practice initiates the invention of an emancipation process where autonomy and maturing are shown as an argument constructed in the process of confronting a colonizing knowledge, which begins to be substituted by other knowledge in the boundary space: oh, a lot, a lot of change!We mature, we are mature together, we mature as people, and your experience gives you self-confidence; your self-confidence helps you to do better work, and your self-confidence helps you to treat the mother in a more effective and affective manner.I think it is personal maturing together with professional maturing.For me, this generates a lot of change (E11).
In order to comprehend the critical reflection proposed, an attitude that refuses to conform and resign to the current reality becomes necessary, and the will to struggle for alternatives is required. 15In this reflection, we think that comprehension of the epistemological rupture is possible by seeking to understand the transformations contained in this reality.
By residing on the boundary, a balance is inevitable between what of the old remains and what should be abandoned.One characteristic of the selective use of traditions is to choose from one's past that which one wants to retain and that which one wants to forget or change, but it is to live in a time between times to the new situations; Sometimes to subvert the plans and previsions leads to creation and to the need to take advantage of opportunities in hopeless situations, which leads us to resort to everything that can save us.The subjectivity of the paradigmatic transition is that for whom the future is a question of life or death. 11The rupture is a time of death that brings the new to light; the process is sometimes painful, as expressed in the following statement: [...] what really challenged me was to understand that within the maternity ward, although I had knowledge, I was nobody; there were a lot of limitations, I lacked autonomy and the power to decide with the woman.That made me feel […] hopeless is the term, because you are being questioned all the time, having to respond, and a lot of times you do all this and they go right over you, like a tractor.I began to understand that that space was no longer mine, and if I wanted to continue in this model, in this different way, there was no going back, because I no longer believed in that, and I would have to jump over the line.Going back was not an option.I had no choice; I had to change internally and go forward in another way, or, I don't know, to die for obstetrics.I think that it was to die for obstetrics, because I would not be able to do it in that way, to subject myself to continue in that other way.

I don't know if I would have given up! I think this now, but don't know how it would have been, if maybe I could have had another route, but at that moment it was what motivated me (E16).
The conditions for the search for change are put into place.The offer of the possibility beckons, and although that which is desired as the future is still not clearly shown, the provocation points to what we do not want.
In their discourses, the nurses demonstrated the need for theoretical study to make changes of attitudes in the practice, as a cross between theory and practice, and the relationships between both.The subjectivities that emerge from the paradigmatic transition delineate the occupied boundary space.In the exploration of subjectivities, the emancipatory practices appear which are formulated considering and sharing with the woman, in an emancipatory relationship for both.The contradictions and creative potential in the frontier space are the conditions for transgression of the limits, where death is present and arrival to the other condition is necessary for change of the obstetrical practice.Such a situation depends on the force generated by the energy of the unease and conception of social alternatives to negotiate in the constellation of powers.
In this sense, we understand the practices experimented by the obstetrical nurses and women as a possibility of the emergence of an emancipatory knowledge, as the following statement exemplifies: there is no other way; I think that the woman that we care for is the aim of our work.When I orient the women, I pass knowledge, and this makes me really happy.I seek to tell them about the practices, because I am experienced, but with heart too.I understood that birth is a physiological act (E3).
"Today the objective is the continuation of the subject by other means.:83 The emancipatory knowledge-practice relationship presupposes a conception of subject/object constructed by modern science. 13

Modes of functioning of constellations of power: they fix boundaries or open to new paths
We understand that a complex web is woven when the nurses' obstetrical practices take place in processes of transformation, and tense social relationships are delineated in discursive practices, which reflect a space of paradigmatic transition.The challenges appear and emerge the silencing of the knowledge, through a constellation of powers, showing that the task is complex.It consigns us to that which we understand as power in its multiple facets, and permitting that these are expressed, take form, and, in the act, in the event indicate an option for the path to follow; the distinction is valued.
Delving into the idea that the actions occur in an unstable, unknown space called boundary, which abandons tradition, the power that each individual has or what is subordinate tends to be exercised more in the opening-of-new-paths mode, than in the fixing boundaries mode.This is because the sociability and subjectivity of the boundary are ruled by limits, and the transgression of these limits is based on complexity, as the possibilities are multiple.The relationships come from the meeting between users and professionals of the care, and between the professionals and their ways of caring and treating.:351 The participants tell us their experiences and present us with everyday forms of performing their practice.Here we highlight one of the statements, to help in reflection of this analysis.The respondent describes events to us, exemplifying her decisions for one practice that she judged to be appropriate for the women user at the time, narrating her context.The question was whether to perform an episiotomy or not, and, when describing the scene, the nurse recounted that during the attendance of one user for whom s/he was caring, at the moment when the baby was emerging from the vagina, one of the physicians from the on-call team entered the room with a group of medical students, and began to narrate the steps that the nurse would take moment by moment, before she had done them.He said: [...] 'she is going to do the antisepsis, and now give the anesthesia, and then do the episiotomy' [...].The nurse continues: and I didn't do the anesthesia nor did I do the episiotomy, and they looked at each other.There was a silence and serious air in the room, and he explained to the students, saying that sometimes the nurses don't do episiotomy, but he didn't look at me.I felt pressured at the time, but I did not feel like doing the episiotomy, and there was no need to, and I didn't do it, and the baby was born really healthy […] (E10).
Recalling the event, the feeling presented by the nurse expressed that she felt secure and confident in her practice, which was known, and flowed independently, and was greater than the pressure that could make her hesitate and doubt her evaluation.What may appear very simple is illustration of the complexity involved in the moment of the decision for a practice, and the long path that we follow when it is a practice based on scientific knowledge and relationships that make them occur in the everyday.In this case, the voice of the woman user, who could influence and say which interventions would be acceptable for her body, still does not emerge.But in the constellations of power we focus the view on the competence of the professional to carry out this practice, in an autonomous and decisive manner.
In this context, the central problem is how to imagine a subjectivity sufficiently apt to comprehend and want the paradigmatic translation, and to transform the unease into emancipatory energy; a subjectivity that wants to perform in the paradigmatic competitions, whether at the epistemological level or at the societal level, to confer a growing credibility to the new paradigm, however provisory and reversible that it may be. 11 this perspective, the everyday relationships are expressed through confrontation, and understood as obstacles to be overcome.That is what we observe in the following statement: well, in a hospital institution, the challenges remain the same.It is the confrontation of medicalization, confrontation of the corporation; it is the relationship with all of this, it is a relationship with the majority.This majority are our medical colleagues that question the hospital culture and nurse colleagues, and they also hold forth a lot, but in practice it is not exactly like that, but they have a pleasing discourse that the people believe, so this is also annoying.And I think that my way of working is good, and I am really good.But I am not a miracle worker, what is it [to work miracles]?It is the nurse's imagined humanized birth, it is the transformation of the super-nurse, it is that which s/ he is able, in this universe, to do a job as that which we imagine, to bring the imagined to a reality that is so rigid and hegemonic.I think this is what it is to work miracles!(E1).
It is a challenge to bring the transformed knowledge and practice to reality, and find space in the hegemonic hospital thought and practice.In order to be efficient and not create frustration, a determined emancipatory relationship needs to be integrated into a constellation of emancipatory practices and relationhsips. 11o that these emancipatory relationships are established in constellations, they should be stimulated and favored in spaces where they can be anchored.To find these spaces is also a challenge, and through these relationships, we can recognize the variability of the constellation of powers that structure the local policy, the academy and its place of knowledge, in addition to groups that may list their interests, where we know that these relationships, by involving material and immaterial inequalities, are unstable: one minute they stimulate participation and the next they refuse the offer of opportunities, as one nurse states below: I think that the challenge is you to try and maintain this stressful routine.Because eventually you get tired.You believe, you bet on a model, and then you begin to look for strategies.I am like that, when I am going through some situation that is bothering me, I don't know how to live with the discomfort, and I have to make use of some strategy so that I don't suffer; So if something is bothering me a lot, I will try to change it.I am not going to sit around complaining all the time, like I see some people complaining all the time.I don't know how to do this; I have to make some effort to change things (E10).
On the other hand, to measure inequalities from unequal exchanges is not easy, as relationships of power do not occur in an isolated manner, but in sequence or in constellations.These constellations configure in a group of relationships between people and social groups that are not entirely predictable. 11The search for equality is encouraged with the offer of opportunities, but it is important that the groups know how to express their interests, have a collective project in the various spheres that, by showing their distinction, also show their differences; the priority of one specific group may not be for the other.
The nurse presents the manner by which, in the everyday, s/he seeks to overcome the limiting mode of the relationship of power, to find space that is considered, seeking distinction, as in the following statement: It challenged me and still challenges me today.It was to differentiate the care provided to the woman in labor by the physician from the care given by the nurse.This drove me a lot.To show that we are able to do distinguished work.This care is glaringly better.I am not diminishing anyone's work, but I think that the doctor does not work from the side of the bed, and a woman in low-risk, vaginal birth labor needs bedside care, needs back massage, needs help bathing, needs conversation, needs to breathe, walk, sit, and it is this that drives me.To be able to demonstrate our capacity to provide good care (E11).
To measure the inequalities is also to evaluate up to what point and in what way they affect the conditions of life and work, in addition to the trajectory of the people involved in the space in which the relationships are established.The capacity of the groups to organize their interests to participate with autonomy in the processes in which they are engaged can open spaces in the constellations of power.The modes of functioning of the relationships of power point out a dualism that reveals a double character in its poles, exemplified by the possible and impossible, thinkable and unthinkable, desired and undesired, legitimate and illegitimate.
What makes a social relationship transform into an exercise of power is the way in which the interests of the parties are treated in the relationship, and how the dualism is presented, which can either set boundaries, inhibiting different expressions, or be permissive, by opening routes and amplifying spaces to promote more equalities, and placing power in relation to the possibilities of giving potential or decreasing potential. 11t is important to create spaces and networks in which the exercise of open and honest dialogue becomes a condition to show the interfaces of knowledge between professionals and services.To construct in these spaces, in partnership, a system of conflict resolution, where limits are clearly established. 16The influencing factors in this constitution point to a positive individual attitude, support offered by the institutional structure, and permanent evaluation of resources and results for a practice suitable to the needs of the women being cared for.
The break varies according to the context, and the moment can be subtle or shocking.The context is also part of, and decisive in, shaping the reality of health, and emancipatory possibilities emerge from the friction of these agents and their capacity for internal and external negotiation with this reality.When this emerges in the context of the constellations, in the sense of amplifying the offers of opportunities, added to the decision to delve into the opportunity, this can contribute to make possible what once appeared impossible.

CONCLUSION
Considering the object and objectives proposed, to analyze the meanings attributed by the nurses to the changes of their obstetrical practice, through the concepts of crossing boundaries and constellations of power, both used in the theoretical framework of analysis, we obtained results that produce reflections about the obstetrical practice of the nurse.
To experiment a new practice involves overcoming the known limits to find autonomy, configured by a knowledge and practice with emancipatory possibilities.The social actors of the study describe crossings in the direction of an unknown knowledge and practices, with various motivations and questionings with the experiences lived in this scenario.The crossings, in this direction, initially unknown, apparently come from the boldness of seeking and experimenting the new and transcending the limit; to resignify the approach provokes new experiences and configures another reality and other limits.
With the proposal to analyze the feelings attributed by the nurses to their practice, and the potential for changes between contradictions and hesitations, we found in these results a desire for changes, and the search to solidify them generated spaces in the constellations of power.The participants of this research establish relationships with the context of the macro processes, represented by strategies such as change of environment from obstetrical center to intra or extra-hospital vaginal birth center, producing a knowledge centered on the woman as protagonist.These actions, when solidified in the institutions at the local level, in which they were inserted in micro processes, formulated a web of local relationships.By conquering the success measured by the satisfaction of the women user and nurse him/herself, practical experiences showed scientific evidence.These encouraged trust through new practical experiences, generating changes and possibilities to deepen in the choices, and to mature as a professional, capable of rethinking his/her practice and valuing the production of knowledge in the everyday of the obstetrical practice.
To think about geographic space as a boundary helps us to reflect and analyze from the context of the crossing between theory and practice as a space of paradigmatic transition.This made it possible to give meaning to the existential experiences, which are almost always contradictory, intense and at the limit, in an individual or collective manner.To us, to interpret them as a privileged form of sociability appears to be a contradiction.However, in the different scenarios, to be at the margin of the conventional obstetrical practice does not mean to live a marginal life, but it is a provocation that can guide the exploration of the possibilities and desire to make the margin center, or to leave the margin and return to the center, in a constant movement of autonomy and dependency, benefits and risks, approximation and distance.
In this context, to constitute new subjects implies that they are not resigned with the unsatisfactory situations the entire time, that they do not have the arrogance to change the world, but the clarity to seek and take advantage of spaces open in the constellation of power to interact with a constellation of knowledge.
In these processes, elements are present that, while they appear to be restrictive from the perspective of finding more exits, either individually or as a group, amplify and configure more spaces in the constellation of powers in dispute, making clear the competence and reliability to confront the challenges in this professional field.

8
Data from the healthcare units of the Municipal Department of Health and Civil Defense of Rio de Janeiro show the obstetric and perinatal indicators results from 2007 to 2010, showing the values for births performed by obstetrical nurses, in which the rates of live births in the municipality were 29,881 (2008), 32,941 (2009) and 32,626 (2010).Annually, the proportion of births performed by obstetrical nurses was 23.8% in 2008, and 19.0% in 2009, and in the first semester of 2010, 21.7% of the total births performed in the six units cited.It is worth emphasizing that the participation of the nurse in this care has shown a significant percentage in vaginal birth care, with the proposal of minimum intervention in the labor/childbirth process.Considering this context, we selected the guiding question: what meanings does the nurse attribute to obstetrical practice in childbirth care?