RESEARCH ARTICLES

Obstetric nurses' practice on emergency wards under the Cegonha Carioca Program

Jane Marcia Progianti^I , Adriana Lenho de Figueiredo Pereira^II, Carla Coutinho Sento Sé^III

^IObstetric Nurse. PhD in Nursing. Associate Professor, Researcher of the Research Group on Gender, Power and Violence in the Health and Nursing and Prociência Program of Rio de Janeiro State University. Brazil. E-mail: jmprogi@uol.com.
^IIAdjunct Professor of the Maternal and Child Nursing Department of Rio de Janeiro State University. Brazil. E-mail: adrianalenho.uerj@gmail.com.
^IIINurse and Master by the Program of Graduate Studies in Nursing of Rio de Janeiro State University. Brazil. E-mail: carlacsentose@gmail.com.

DOI: http://dx.doi.org/10.12957/reuerj.2014.12888

ABSTRACT: The goal of this qualitative study was to discuss obstetric nurses' practice on emergency ward at maternity hospitals linked to the Cegonha Carioca Program. The study is based conceptually on the notions of reiterative and creative praxis. Data were collected between January and March 2013, by semistructured interview of eight obstetric nurses at four public maternity hospitals. The analysis of their statements involved the following steps: sorting, classification, data categorization, and final analysis. The results showed that the practice of user embracement was ambivalent and that the visits scheduled to maternity wards for the purpose of preparation and familiarization with childbirth and risk classification and aftercare guidance, were practices that supported and reinforced medical care. It was concluded that obstetric nurses' practice during user embracement is a reiterative praxis and that, although based on humanization, is strongly influenced by the hegemonic biomedical model.

INTRODUCTION

In 2010, the Ministry of Health published the Guidelines for Organization of the Health Care Network, under the Unified Health System (SUS), by Decree nº4279 of December 30th, 2010. In this legislation, there is a definition of the Health Care Network (RAS) as being organizational arrangements of actions and health services, with different technological densities, which while integrated through technical support, logistics and management systems, seek to ensure the fullness of care¹.

The RAS is characterized by the formation of horizontal relations between the points of primary, secondary and tertiary attention. These health care points are understood as spaces where proffer certain health services, through a unique production, and are also important in order to meet the objectives of the network. They differ only by the different technological densities that characterize them¹.

In this perspective of improving the organization, operation and resolution of the health care network in maternal and child health, were released simultaneously, the Rede Cegonha in Federal ambiance, and the Programa Cegonha Carioca, in the city of Rio de Janeiro, on March 28, 2011.  

This program, in turn, seeks to widen and improve the care given to pregnant women in the city of Rio de Janeiro. It consists of three modules: prenatal care, transportation and reception or hosting. The prenatal module intends to allow pregnant entered in prenatal primary care, prior knowledge of the maternity ward of reference for the care of delivery. The transport module is characterized by the availability of mobile care service to mothers in need of transportation from home to the maternity ward².

Finally, the host module tries to reorganize and qualify obstetric emergencies in municipal hospitals. Ensuring continuity of care between prenatal and delivery times is considered an important strategy for reducing maternal and neonatal mortality².

With the implementation of the reception host module, a new scenario of professional practice of obstetric nurses in emergencies municipal hospitals was instituted. In view of this new scenario, this study discusses the practice of obstetric nurses in emergencies of the hospitals linked to the Cegonha Carioca Program.

LITERATURE REVIEW

The practice of midwives in the host module cannot be analyzed in a pragmatic way, as a mere objectification of recommended programmatic actions. It should be analyzed as a consciously guided activity, an inseparable whole theory and practice, which has an ideal, theoretical side, and a material side, properly practical. These dimensions cannot be isolated from each other, which brings us up to the concept of praxis³.

Praxis is human action on the matter and creating a new reality, one can speak of different levels according to the degree of penetration of awareness of the active subject in a practical process and with the degree of creation or humanization of the transformed matter evidenced in the product of its practical activity. There is a distinction of two practice levels, the creator (reflective) and reiterative (spontaneous or imitative), which form two poles of constitutive dialectical tension of human praxis³.

The creative praxis is crucial to produce a new reality. The reiterative one does not produce a qualitative change of this reality and does not transform it creatively, though it enables the area that has already been created, to multiply quantitatively what was once already created³.

METHODOLOGY

This is a qualitative research, which data collection was conducted in four major public hospitals in the city of Rio de Janeiro, which have a host module team acting in their emergencies. The data collection period was from January to March 2013.

The subjects were eight midwives, who worked for at least six months in the host module in a studied municipal maternity hospital, and agreed to participate.

The research was approved by the Research Ethics Committee of SMS-RJ, under No. 92/11 in accordance with Resolution 466/2012 of the National Health Council, which directs research involving humans. The interviewees signed the consent form.

Data collection was performed using a semi-structured interview. The interview guide applied to the obstetric nurses consisted of six questions to characterize the deponent and five to respond to the objective of this research. It is noteworthy that to preserve anonymity, the interviewees were identified by letters and numbers, according to interviews order: Nurse (E1), Nurse (E2) ...

The statements followed the following steps: data triage, through the interview transcript, rereading the transcripts, data classification, with horizontal and comprehensive reading of the texts and cross-reading of each presented subset and final analysis⁴.

RESULTS AND DISCUSSION

Following this analytical route, three categories were built: Reception as ambivalent practice; Scheduled visit to motherhood: preparation and ambiance for delivery; and risk rating and post-consultation: support practices and the improvement of medical care.

Reception as ambivalent practice

The reception, despite the diversity of views and settings, is a construction process in SUS where health actions express the implicit rationality in health care models, which is a way of thinking, design and being in the world at a given time, which determines the actions, sets standards and produces senses, meanings and social practices⁵.

In this sense it was revealed that some nurses conceive the reception as being listening on women's issues, reception and security and performs this throughout the whole care process:

The reception is listening, it is you welcoming, hearing, giving security. It is the woman feeling welcomed, feeling good to expose their problems, which are not always obstetric. (E1)

The reception happens all the time, from her entry [user] until the time of departure, welcoming when you check vital signs, after receiving medical treatment, the moment when she goes through the medication. (E2)

These documents also denote that the view of the nurse focuses on the problems of women in amplified form and their feelings of well-being. In this perspective, the reception shall guide their practice because it is continuously present in the professional attitude. It can be considered a technical-assistance action focusing on relationships, which implies a way of operating the health work processes, such as listening, building bond, the guarantee of access with accountability and the solvability of offered care. Therefore, it can be considered one of the most relevant guidelines of ethics and aesthetics of the National Humanization Policy of the SUS^6.7.

However, the hegemonic mode of production in health is guided by the biomedical model, which has an emphasis on medicalization and design of risk, so that there is a tendency to turn all complaints into disorder or organic disease which can be treated and depends on biomedical technologies⁸.

This hegemonic worldview present in the attendance areas influences the practice of nurses, so that the reception was also designed as an attention to current complaints of women to solve emergency problems.

The reception is about listening. I hear the complaint and have to be aware if it is not a bleeding. If there isn’t a doctor down here, I put (them) in rest, install IV and oxygen, harvest the blood tests and send them to the laboratory. (E5)

The last statement shows the reproduction of the clinical model by the nurse, centered on the complaint of the disease. This sets the professional actions, restricting the space for educational activities, for health promotion and prevention⁵.

This design clearly shows a facet of midwifery that emphasizes the biological knowledge, the rules and instrumental standards of the profession and the nuclear position of the doctor in health care. In this perspective, the reception was reduced to another procedure, the design of which was not incorporated into the professional attitude of the nurse as to be present throughout the process of care, demonstrating care production as fragmented into a series of partial operations. This division becomes a division of man himself, putting his whole being at the service of a single activity³.

The way it is operated, the reception module denotes the assignment of welcoming, of carrying out the subjective and relational dimension of care to women, is headed by nurse and limited to the small space of a room in the maternity emergency ward.

Working conditions in that room are very difficult, because the space is small, restricted. I think the mother should have a little more privacy. We have only one screen. Hence, when I have to look, I realize that the pregnant woman feels clearly troubled. (E8)

To this day I think our room is not a cozy place, is not a place that we can give the pregnant woman privacy, to talk, to receive her companion in. (E7)

Therefore, there is a clear technical and spatial segmentation between the place provided for the practice of reception and to the practice of clinical and obstetric care, which does not achieve the programmatic ideals of the host as a way to operate the health work processes⁹.

Scheduled visit to the maternity: preparation and setting for the birth scene

Every human action requires some awareness of purpose, which is subject to the course of the activity itself, that is, the purpose is the expression of a certain attitude of the subject in the face of reality³.

In this perspective, the host module, in obstetrics, introduced differentiated actions to what is commonly performed in emergency rooms. The scheduled visit of pregnant women was established in the third trimester of pregnancy, and her companion to the hospitals of reference. This is a continuity strategy of the line of care between the departments of primary care, who perform prenatal care, with hospitals belonging to the secondary care, as a security reference for the delivery pursuant to the Federal Law nº 11634 of December 27 2007. This law guarantees the right to knowledge and prior binding to the maternity in which the birth and the care in case of complications occurs.  

During this visit, the physical dependencies of motherhood, discussed issues related to labor and the time to seek the maternity are presented, as described by the nurse:

We still have the assignment of these educational workshops for women to know the unit to which she is referenced and at what point she will seek emergency precisely to not be a stranger. So we try to put into the educational workshops the main situations of complaint that they may have, we focus not only on the issue of labor signs, as the final delivery process but also towards main emergency situations for them to seek care. (E4)

It is noticed that the activities of the visit are considered as practices of minor technical complexity that do not require the performance of a specialized professional in obstetrics.

On the other hand, the guidelines offered to pregnant women at the time of this visit cannot be understood properly as an educational workshop. The health education process, under the perspective of knowledge sharing and autonomy of the individual in the process of knowledge construction, is not a simple task and is given in a brief meeting at the institution. Health education means to effect the process of reflection of reality through dialogue and exchange of experiences among the subjects, which raise their awareness about themselves and their reality¹⁰.

Besides this narrow perspective of educational activity, at the time of the visit there is also the distribution of a bag decorated with the program logo, which has clothes for the baby, named as the Cegonha layette. The distribution of this outfit is designed to encourage the adherence of women to prenatal care and increase service coverage in the city of Rio de Janeiro.¹¹

However, its distribution also denotes the underlying welfare logic in implementing the Program, which follows the tradition of the social policies directed to the poor in the country. These make up the predominant class of users in public health services.

Therefore, the practice of the nurse towards a scheduled visit in the maternity assumes senses of technical, operational and policy order. The first direction are the activities they perform in the host module, which are strategic to the warranty of rights for pregnant women in relation to the reference to the delivery and knowledge of the environment in which their child will be born. The visit is also an opportunity to acquire information by pregnant women about when and in what situations they should follow the emergency care of the maternity, which helps with the reorganization of this gateway to secondary care.

Finally, it allows the propagation of a programmatic action of government management through the gift offer for the pregnant women enrolled in the Cegonha Carioca program, which usefulness transcends the goal of improving obstetric care.

Risk classification and post-visit: support practices and the improvement of medical care

The Cegonha Carioca Program states that the user, while getting at the emergency room, must be received by the administrative staff responsible for the dispatch of the Emergency Service Bulletin and subsequently be forwarded to the room where they will be classified by risk. This is seen as a technical assistance tool that organizes care on the basis of risk and vulnerability of the user and not the order of arrival, which is potentially harmful to the health of pregnant women and their unborn children in urgency and emergency situations¹¹.

In this room, the obstetric nurse receives the pregnant woman, checks the vital signs, identifies the risk and establishes the priority for medical care in accordance with a standardized protocol, as described by the nurse:

I receive the pregnant woman, I hear what she has to say to me, check the vital signs and classify her according to their urgency or emergency, prioritizing or not the medical care. There is a protocol that we're observing according to what she is feeling, what we are seeing, in order to prioritize care, and the time she can wait and not aggravate her situation. (E6)

Although establishing the priority for the doctor's care, this professional is not always present in the team of obstetric emergencies, requiring accountability from obstetric nurses for emergency assistance, as described in the following statements:

My activities are welcoming, listening to pregnant women, and prioritize the medical care. There isn’t always an obstetrician in attendance, or, there are these and they are busy, and we need to act in assessing her in touching or even in assistance to childbirth or newborn already delivered. (E1)

As you listen to the story and complaints of women, you will classify by the time needed for her care. But in our unit we have problem regarding the size of the medical team. But the main function is to detect the risk, the degree of risk for this woman, the need she is presenting at this time and try to minimize her situation. (E4)

Reducing the number of physicians in public health services is one of the consequences of chronic underfunding and of the structural difficulties of the health system, the low pay and the difficult conditions of health work. This precarious work is alienating the doctors from the public health service, as there are more favorable working conditions for the private sector.

The media have disseminated the lack of these professionals in the public health sector. The deficit of these professionals affects care in emergencies and causes the elimination of hospital beds. The municipality of Rio de Janeiro hold public tenders for its permanent staff of doctors, but low pay does not favor the retention of these professionals¹².

Just as doctors, nurses also face this problem in working conditions. Despite the differences in nursing and medicine professionalization process, the issues of gender and social class are at the heart of social and sexual division of working in the health sector, and produces social and professional distinctions that impact on differentiation of social and financial value of work for doctor and nurse.

In addition, the organization of work in the hospital has a bureaucratic and hierarchical order also determined by these issues and this shapes the division of tasks and responsibilities in the institution. Through this system, there is the control of time, processes and execution modes of activities and consequently creates the commands, responsibilities, hierarchies, power relations and the chains of interactions and interdependencies of the subjects in the labor process¹³.

Under this system, the actions taken by the obstetric nurses in the emergency reception module support and streamline medical care, but also reinforces it through the practice of post-reception. This occurs after the medical attention when the woman returns to the nurse to clarify possible doubts about what was said by the doctor and mediate the resolution of certain situations that still require care:

We fill that role [risk classification sheet], I mention her complaint and if she has a complaint, I forward her for medical care. After this attendance she returns to me, to see if she was orientated, and if she has any doubt. (E3)

Considering the ministerial recommendations for the organization of the reception with risk rating in SUS emergency services, the additional activity of the post-reception takes on a perhaps unprecedented conformation, in which the reception held by the obstetric nurse is the initial moment of service in the sector of emergency of maternities. It is also the moment of its resolution, whether through the assistance continuity indication of prenatal primary care or for follow-up in the other sectors of the maternity.

In view of the creative praxis, that fact could be crucial to produce a new reality or a qualitative change of this reality, even including the creation of a social demand for SUS users to claim their rights to participate in the construction of their own care, through their knowledge and needs¹⁴.

CONCLUSION

For being the praxis of the obstetric nurse in a fragmented host module, based on protocoled actions and with centrality on the doctor's actions, it is concluded that it is a reiterative praxis.

This reiterative praxis prevents the creation of alternatives to the concrete transformation of the mode of production of obstetric care and the overcoming of the hegemonic biomedical model and the relations of production arising from it.

This way, despite the obstetric nurses having an education and actions that identifies with the ideals of humanization, when it comes to providing the woman and her companion a visit focused on the completeness of the presented needs, these professionals have a structured practice by market logic and productivity. This indicates the direction of productive reorganization of the health work in the city of Rio de Janeiro.

The hosting is ambivalent, sometimes is seen as a reception, sometimes it encompasses the whole service. This practice is influenced by the lack of physical infrastructure of some units and by the logic of the established protocol.

This institution of protocols and the filling out of the classification records collaborate towards that the nurse gives more emphasis to the protocol procedures, which are objective and measurable data from the production of the program activities and to the detriment of subjectivities of nursing care.

It is suggested to managers and nurses in the host module to devise management strategies that can balance the actions of protocol enforcement to the subjective actions of nursing care, for example, to establish a qualitative evaluation of the service, create groups of educational practices that are emancipatory for citizenship.

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