Historical and epidemiological evidence corroborates that a qualified care provided by professionals during the prenatal period has a significant effect in reducing maternal deaths. There is a consensus among the World Health Organization (WHO), the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO), the United Nations, and the International Confederation of Midwives (ICM) that a clear definition of indicators is needed to establish the profile and the essential skills that professionals need in order to offer an adequate accompaniment to the women in this period.³

Therefore, through quality prenatal care, labor and delivery will have the participation of women as active subjects throughout the process, as recommended by the Humanization Program for Prenatal and Birth (Programa de Humanização no Pré-Natal e Nascimento, PHPN), established by the MoH in 2000. From the perspective of the public policies, of programs aimed at women's health, and of instruments both national and international, the opportunity for women to be able to make informed choices during delivery is a right that needs to be considered, valued and, especially, fulfilled.⁴

Accordingly, even before the creation of the PHPN, in 1996 the WHO published the guide for the care of normal deliveries, the result of international studies based on scientific evidence, with the aim of promoting healthy childbirths and combating maternal and neonatal morbidity and mortality by means of good delivery and birth care practices. The dissemination and implementation of the practices contained in the guide can contribute significantly to the reduction of preventable deaths, as there is an emphasis on the promotion and rescue of a more natural and physiological delivery and birth.⁵

Over the years, nurses have conquered a leading role as a health professional. In this sense, they become allies in the search for the realization of good practices in delivery and birth care, encouraging and valuing women's autonomy.⁶

This study is justified because it addresses a relevant topic since, in terms of the research scenario, there is a gap with regard to studies in BC (Basic Care). Delivery care is still perceived as a practice of the nurse who provides care in obstetric centers and, for this reason, the research studies have been focusing on the practices within the hospital context.⁷

In light of the above, the following question arose: What are the perceptions of BC nurses about the good practices in delivery and birth care from the perspective of the Evidence-Based Practices (EBP)? It aims to identify the BC nurses' perceptions on the good practices in delivery and birth care from the perspective of the EBP.

Method

This is a descriptive and exploratory research based on the qualitative approach.⁸ The research was carried out in a city located in the central region of the state of Rio Grande do Sul, Brazil.

The inclusion criteria for the participants were the following: belonging to the Nursing teams in the municipality and accompanying the usual risk prenatal care in BC. Professionals who were on vacation or absent from work on leave of any nature during the period of data collection were excluded from the study.

The total population consisting of 45 nurses was submitted to a random selection by lot. Thus, the study was composed of 20 nurses, 10 working in the Family Health Strategy (FHS) units and 10 in BHUs. Of these, 10 participated in this research, 5 from the FHS and 5 from BHUs due to data saturation.

Data collection took place in the months of April and May 2018. To obtain the data, the vignette technique was used, which allows for a brief and compact description of a situation in which the interviewees are invited to reflect. It is structured in order to extract information about perceptions, send a message, and identify behaviors, attitudes, opinions, and knowledge about the topic in question.⁹

For this research, the vignette was prepared with fragments of the Document on “Good practices in delivery and birth care” by the WHO, which addresses the care practices for normal delivery, their classification, and the incorporation of the good practices in delivery care and reduction of the number of interventions, designed for the purpose of achieving the research objective, and presented to the participants.

Then, the semi-structured interview was conducted using a previously prepared script. It is believed that, in this way, the interviewer is provided with a better understanding and practicality to capture the perspective of the participants, unlike free interviews that tend to generate an accumulation of information, generally difficult to analyze and not showing a clear view of the person's understanding that was interviewed.¹⁰

The interview was recorded, with the participants' knowledge and authorization. For the analysis, Content Analysis was used,¹¹ consisting of three chronological poles: pre-analysis, exploration of the material, and treatment and interpretation of the results obtained. In the pre-analysis, the data obtained in the recordings were transcribed in a text editor, constituting the corpus of the research. The recordings were listened to and a floating reading of the material collected in the interviews was performed.

The questions to the respondents revolved around the understanding about the good practices of delivery and birth, in the use of some support material from the MoH or the WHO to assist in the prenatal consultations. Also, about the guidelines regarding what should and should not be done in the delivery process, and about benefits and challenges related to the guidance of good practices in delivery care during prenatal care.

Then, the material exploration phase began, considered as the realization of the decisions made in the pre-analysis. At that time, the Registration Units (RUs) were selected, selected by the presence or frequency with which they appeared in the texts, detaching themselves from them in a significant way for the analysis objective determined for the study.¹¹

In the last stage, text clipping operations were carried out, in which words, phrases, or expressions of the speeches that referred to the theme in question were written on colored sheets. It was decided to use yellow sheets to identify text clippings by the FHS professionals and pink sheets to identify the professionals from the BHUs. Subsequently, chromatic analysis was applied, in which the RUs that showed affinity were grouped and, on brown paper, separated by means of post-it notes of different colors.¹¹

In order to preserve anonymity, the participants were identified by the letter E, followed by their interview number, and by the abbreviation UBS or ESF (the Portuguese acronyms for “Basic Health Units” and “Family Health Strategy”, respectively). The ethical precepts were ensured in accordance to Resolution 466 of December 12^th, 2012.¹² All the participants signed the Free and Informed Consent Form. The study was approved by the Research Ethics Committee of the Federal University of Santa Maria, under the CAEE number: 85190018.0.0000.5346 and opinion No. 2,593,481, on April 11^th, 2018.

Results and discussion

The study participants were aged between 20 and 60 years old, with a mean of 39. Their training time ranged from five to 30 years and their experience in the municipality's BC services was from one to 28 years. No participant had any other employment contract.

Regarding the qualification in prenatal care, four nurses reported having taken a qualification course during BC Planning, which included a course on usual risk prenatal care. Planning is a health care planning process which aims to strengthen BC and to reorganize work processes.¹³

Regarding the logic of performance of the prenatal consultations, seven participants reported doing so intercalately with the physician in the health unit. Therefore, three respondents answered that they only do the first consultation, and that the rest are the exclusive responsibility of the medical professional.

The collective educational activity directed to prenatal care is organized by the nurse and developed in the health unit by means of groups of pregnant women by six participants, four of whom work in the FHS and two in BHUs. Still, four nurses reported developing the educational activity only by means of an individual consultation, three of them working in the BHUs and one in the FHS.

After analyzing the data, the search result was grouped into a category:

Evidence-based practice and the perceptions of good practices in delivery and birth care as a tool for quality prenatal care

With the intention of establishing adequate and safe practices for obstetric care, the WHO has developed recommendations for delivery care according to the EBP.¹⁴After the presentation of the vignette, it was possible to discover in the statements of the participants the scientific knowledge they have in relation to the good practices, showing that the EBP is a movement little found among the interviewees' routine, as noted below:

[...] it’s a well-made prenatal to begin with. A well done prenatal care where they clarify all doubts and go to [...] to the hospital or to the home of the pregnant woman, in short, without a doubt and with normal delivery. (E7-UBS)

I believe that a delivery that has no harmful intervention for pregnant women [...] inducing with medication or accompanying the birth of the child naturally, I think that everything that goes beyond that, is no longer a good practice. (E10-UBS)

Nursing has been facing a cultural change over the last decades. It is increasingly expected that nurses understand the importance and also carry out research studies which support their professional practice by means of data collected through scientific research studies, adopting an an EBP.

In the area of obstetrics, the use of scientific evidence is essential to modify the paradigm of delivery care, in which the woman is not the protagonist, often subjecting herself to unnecessary interventions.¹⁵ In the nurses' testimonies, a subjective understanding is perceived, not based on the best scientific evidence/productions for providing care to women and newborns.

In relation to safe and appropriate practices within the context of delivery and birth, the following statements demonstrate that the professionals associate the humanization of care and the benefit to the mother-child binomial with the EBP, but they talk generically about the subject matter.

[...] they are practices that theoretically have to be based on evidence, which prove by "a" plus "b" that they are beneficial for the pregnant woman and the fetus. (E5-UBS)

[...] it’s the union of both human and scientific issues. (E4-ESF)

It is worth mentioning that health care practices based on scientific evidence are among the actions of the Rede Cegonha (Stork Network), which aim to improve the quality of prenatal care.¹⁶ To this end, the Ministry of Health provides health professionals and students with scientific databases with the purpose of inserting the EBPs within the professionals‘ work process and the students' academic training, encouraging a change in the care practices.^17-18

In this context, the construction of care protocols in nursing seeks to meet the legal and ethical principles of the professional practice, the precepts of the EBP and the rules and regulations of the Unified Health System (Sistema Único de Saúde, SUS).⁵ Therefore, knowing and using the protocols is essential in the nurses' practice, since their procedures consider patient safety and the best quality of care, causing a direct impact on health care.

As for the use of support material at the time of prenatal consultations to guide pregnant women in what should and should not be done during the delivery process, the participants demonstrate that the use of these materials is not part of their work routine.

[...] I think there might be something for the consultation, [...] like a checklist to not forget anything. I think it's a good measure, but today I don't use any support like that, not being there at the time. (E4-ESF)

No, it doesn't. I don't use any instrument. (E3-UBS)

The scientific evidence demonstrates that the delivery and birth good practices promote positive maternal and neonatal outcomes. Likewise, the incorrect use of technologies or unnecessary interventions can be harmful to the mother and her fetus.⁷ In this perspective, prenatal care is an element directly linked to the quality of care during delivery and birth, and is related to better health indicators of the mother-child binomial, contributing to the reduction of maternal and perinatal morbidity and mortality.¹

The following speeches refer to the fact that, although there are no support instruments available in the services, the nurses use strategies to assist in guiding on what should and should not be done during the delivery process.

From time to time I read an article, text on the Internet, something like that because we don't have so much contact with the time of delivery [...] we try to guide the right to a companion [...] but the contact we have is very vague. (E6-ESF)

It is worth mentioning that the WHO document entitled “Good practices in delivery and birth”¹⁵ is available online with free access, and presents in a succinct and clear way a classification of the common practices in conducting a normal delivery. It also provides guidance on what should and should not be done during the delivery process.

It should be noted that, in recent years, the web has become part of the daily lives of individuals in different contexts, including the scientific one. It is possible to find academic articles, databases, and digital libraries, among other materials, that are available with easy access. However, there is also a large volume of information that does not have informational relevance within the scientific production.¹⁹

An integrative review study showed a significant increase in the number of publications on humanization and rescue of the good practices in delivery and birth. Most of the research studies on the topic were carried out by nursing professionals (93.3%), followed by medical professionals (6.6%).²⁰

In the following statement it was possible to identify the nurses' perceptions related to some unnecessary interventions during the delivery process, such as:

[...] In the case of an episiotomy, I don't think it's a good practice, the use of oxytocin also for all the pregnant women is not a good practice, the scheduled cesarean section is not a good practice [...]. (E9-UBS)

[...] different from normal delivery, when an intervention is performed it can be harmful to the patient [...] (E10-UBS)

With regard to Kristeller's maneuver, it is described as a practice without sufficient evidence to support a recommendation.²¹ More recently, in 2017, the National Guidelines for Assistance to Normal Delivery contraindicated Kristeller's maneuver and, in the same year, the Federal Nursing Council (Conselho Federal de Enfermagem, COFEN) unanimously approved the prohibition on the participation of nursing professionals in the execution of the maneuver.^22-23 Episiotomy, on the other hand, is a practice that belongs to Category D: practices frequently used inappropriately.

Within this scenario, the concept of obstetric violence emerges, which is mainly translated as negligence in care, verbal, physical, or psychological violence and also the inappropriate use of technologies and the adoption of procedures without the consent of the parturient.²¹ In this sense, when women have access to quality information and understand the pregnancy process, they are able to exercise their autonomy and seek empowerment. It is known that, within the current context, the outcome of a delivery cared for within the good practices guided by the WHO does not only depend on the pregnant woman; however, through knowledge it is possible to gradually change the current scenario.

It is inferred that the nurses understand prenatal care as a beneficial space to guide pregnant women, which makes this moment a good space for clarification.

[...] We guide, remove some of those myths [...] That terrorism that the staff loves to do with the pregnant woman, to make the pregnant woman more confident that the best will be done for her at that moment [...]. (E6-ESF)

In this regard, the role of the nurse is to welcome and establish a relationship of trust, acceptance, and full support for the pregnant women and their families. This support should come from actions that aim to increase the level of guidance of pregnant women regarding rights, risks, and complications. Also, they begin to receive guidance with greater security, demystifying information that is not scientifically substantiated.²⁴

The knowledge included in the WHO document can be considered the beginning of the humanization of obstetric care because, since then, several documents have appeared in defense of normal delivery and of women’s autonomy. In this logic, the possibility of stimulating the empowerment of women with a view to their protagonism during delivery, through prenatal care, was found in the following speech:

[...] Empowerment mainly makes women arrive in labor, when they know their own body, know the changes they will have, the care actions, when to seek a professional [...] that she knows the whole process [...]. (E3-UBS)

An adequate follow-up of the pregnant woman is related to benefits throughout the pregnancy-puerperal process, making it necessary to incorporate strategies that enable an integral and resolute approach.²² However, with the objective of evaluating the prenatal care process, a study carried out in 2012 in the municipality of Santa Maria/Rio Grande do Sul (RS), pointed out that among the guidelines less received by women during prenatal care is the delivery type.²⁵

In the statement below, the weakness in the monitoring of pregnant women with regard to the guidelines on delivery provided during prenatal care can be observed.

As the demand is great, we may not really be experiencing these guidelines, this health education, even with women [...]. (E4-ESF)

Focused on how the delivery will be, since I’m here we don’t work on this issue with pregnant women. If you guide on what brings more risks and forget that part, as if it were not ours, as if it belonged to the hospital's professional. (E10-UBS)

With regard to individual guidance, which occurs during the prenatal consultation, the participants perceive a challenge regarding the difficulty of understanding the pregnant women, evidenced as follows:

[...] Difficulty in understanding is one of the most difficult things. That is why it’s important to guide in all consultations, because you guide four, five, six times and it seems that they don’t understand. (E6-ESF)

[...] The challenge for me is this, we are able to guide in a way that the pregnant woman is confident that it is correct, safe information, that we’re sure that she understood. (E6-ESF)

It is understood that, by knowing the social reality in which the women cared for are inserted and by listening and valuing the narratives of the pregnant women, it is possible to exchange knowledge so that the information regarding the conducts and procedures that involve delivery is conveyed by means of a language more accessible to their understanding. In this way, the prenatal period can be considered the first step towards a humanized delivery and birth, requiring guidance to occur through effective communication between the professional, the pregnant woman, and her relatives.²

With regard to collective guidelines, provided by the group of pregnant women, it is considered a strategy that enables the promotion of shared knowledge, empowering women to make conscious choices in decision making, encouraging autonomy and contributing to the active participation of women and of her partners throughout the pregnancy-puerperal cycle. The educational practices carried out in this period also contribute to the construction of the bond between the mother and the baby.¹⁷

When questioned, guidelines for good practices in delivery and birth were developed, some nurses reported the group meetings of pregnant women in the health units which, in turn, result in good experiences in relation to the knowledge acquired by the women.

[...] The groups are very resolute, because there’s an exchange among them. Those who have had previous experience, they have this exchange with the group. The group also aims to strengthen these pregnant women. Strengthen and clarify. (E1-ESF)

[...] Within the group of pregnant women, in one of the moments we talk about delivery, we talk about the types of delivery, which is more or less the step by step that will happen at the time of delivery [...]. (E9-UBS)

However, some interviewees replied that they did not perform group guidance focused on “good practices in delivery and birth”.

I don't perform [...] we don't do. (E5-UBS)

At the moment she doesn’t have it, and has no plans for this semester. (E3-UBS)

No. Only the prenatal guidelines. (E4-ESF)

Bearing in mind that quality prenatal care is a sinequa non condition to carry out a respectful delivery and birth, knowledge about labor and about the common practices in conducting normal delivery is necessary. Additionally, what should and should not be done during the labor process, that is, to understand what the good practices in delivery and birth are.

Thus, permanent education with an emphasis on good practices in delivery and birth care is needed, aimed at BC professionals, and based on the scientific evidence. The importance of the nurse is highlighted to provide quality care and to provide the necessary support for the pregnant women; however, it is essential that this professional has a care practice supported by scientific evidence.

Conclusion

It was possible to identify that the nurses participating in this study mention the humanization of care and the benefit to the mother-child binomial as part of the safe and adequate practices, understand that prenatal care is an important space to guide pregnant women, and hold the group meetings of pregnant women in the health units. However, they rarely use the EBP in the practice and do not employ support material during the prenatal consultations.

Hindering factors were observed in the work process, such as lack of knowledge, low adherence to the good practices in delivery and birth care, limited time availed to the pregnant women due to the other demands of the health service and to the lack of professional training in the area of obstetrics, the latter mainly being perceived by the nurses of the BHUs. Regarding the facilitating factors, multi-professional work and team actions qualify care, favoring comprehensive and equal assistance, in addition to promoting the exchange of knowledge among the professionals.

Still, it can be understood that permanent education actions are essential and that the reflective practice is a necessary condition, since it is from the problematization of everyday situations that learning becomes more significant. Consequently, care is provided integrally, safely, and supported by means of evidence.

Although the scientific production on the theme of good practices in delivery and birth is extensive, it is still possible to observe gaps regarding the nurses' work process. In view of this, this research may contribute to better understand the practice of these nurses, to perceive the advances and also the obstacles that still exist in nursing care. In addition, health professionals and managers will have subsidies for implementing actions that can guarantee the quality of care provided to women during pregnancy. Consequently, they can bring better outcomes in delivery and birth.

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Corresponding author

Luana Fietz da Silva Raznievski

E-mail: lua_ana@hotmail.com

Address: Rua José do Patrocínio, 26, Neighborhood: Centro, City: Santa Maria – RS

ZIP CODE: 97010-260

Authorship Contributions

1 – Luana Fietz da Silva Raznievski

Conception and planning of the research project, acquisition, analysis and interpretation of data, writing and critical review.

2 – Fernanda Almeida Fettermann

Analysis and interpretation of data, writing and critical review.

3 – Andriele Berger da Rosa

Analysis and interpretation of data, writing and critical review.

4 – Juliana Silveira Bordignon

Analysis and interpretation of data, writing and critical review.

5 – Daiany Saldanha da Silveira Donaduzzi

Conception and planning of the research project, acquisition, analysis and interpretation of data, writing and critical review.

How to cite this article

Raznievski LFS, Fettermann FA, Rosa AB, Bordignon JS, Freitas HMB, Donaduzzi DSS. Good practices in delivery and birth care: perceptions of Primary Care nurses. Rev. Enferm. UFSM. 2020 [Accessed on: Year Month Day]; vol.10, e34: 1-18. DOI: https://doi.org/10.5902/2179769238887