ORIGINAL RESEARCH

The experiences of comfort and discomfort of woman in labor and childbirth

Larissa Lages Ferrer de Oliveira^I; Maria Cristina Soares Figueiredo Trezza^II; Amuzza Aylla Pereira dos Santos^III; Géssyca Cavalcante de Melo^IV; Maria Elisângela Torres de Lima Sanches^V; Laura Maria Tenório Ribeiro Pinto^VI

^I Resident in Obstetric Nursing in the Institute of Integral Medicine Prof. Fernando Figueira. Recife, Pernambuco, Brazil. E-mail: larissalagesf@gmail.com
^II Obstetrician Nurse. PhD in Nursing. Lecturer at the School of Nursing and Pharmacy, Federal University of Alagoas. Maceió, Alagoas, Brazil. E-mail: trezzacris@gmail.com
^III Obstetrician Nurse. PhD in Health Sciences. Lecturer at the School of Nursing and Pharmacy, Federal University of Alagoas. Maceió, Alagoas, Brazil. E-mail: amuzzasantos@bol.com.br
^IV Nurse. Master from the School of Nursing and Pharmacy of the Federal University of Alagoas. Maceió, Alagoas, Brazil. E-mail: gessycamelo@hotmail.com
^V Obstetrician Nurse. Lecturer at the School of Nursing and Pharmacy, Federal University of Alagoas. Maceió, Alagoas, Brazil. E-mail: eli_sanches23@hotmail.com
^VI Resident in Obstetric Nursing by the Institute of Integral Medicine Prof. Fernando Figueira. Recife, Pernambuco, Brazil. E-mail: lauraatenorio@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.14203

ABSTRACT

Objective : to analyze the experiences of comfort and discomfort of women during labor and childbirth. Method: a qualitative descriptive study carried out in three maternity hospitals in Maceió-AL with 40 puerperal women, from July to September 2014, through semi-structured interviews, based on the theoretical framework of Katharine Kolcaba's Theory of Comfort. Results: despite the increase in the humanization of childbirth, many women cannot live this reality, being little heard about what would bring comfort or discomfort to them at the time of their childbirth. The childbirth, the assistance, the companion, the pain, the episiotomy and the increase of pain due to the use of oxytocin are among the main experiences of comfort and discomfort reported. Conclusion: comfort and / or discomfort can influence the woman's satisfaction during childbirth, requiring the health team a humanized look for effective care. Keywords: Women's health; nursing care; humanizing delivery; patient comfort.

INTRODUCTION

The World Health Organization (WHO) has been stimulating initiatives that favor changes in the care of women in the pregnant-puerperal cycle, among which is the implementation of a proposal for humanization of childbirth practice in health services. In this sense, the Ministry of Health created through Ordinance nº 569/2000, the Program for Humanization of Prenatal Care and Childbirtrh (PHPCC), whose main strategy is to ensure improved access, coverage and quality of prenatal care and assistance to childbirth and puerperium. Since the institution of the PHPCC, respect for sexual and reproductive rights and the perception of women as persons appear as priorities in humanized care^1,2.

For the Ministry of Health, humanization comprises at least two fundamental aspects: the first refers to the duty of the health services to receive women, their relatives and the newborn with dignity. For this, there is a need for an ethical and supportive attitude on the part of health workers and the organization of the institution in order to create a welcoming environment and also to break up with the isolation normally imposed on women. The second aspect refers to the adoption of measures and procedures known to be beneficial for the labor and delivery, avoiding unnecessary interventionist practices that, although traditionally carried out, do not benefit the women or the newborn^4,5.

It is important to emphasize that humanized childbirth is characterized not only by the absence of unnecessary practices. In order for a childbirth to be really humanized, the parturients must be fully respected and they must actively participate in the decisions that involve their care so that they take on their role as protagonists, while the health professional is supposed to support parturition^6,7.

However, despite the growing number of issues related to the humanization movement and the inclusion of women as protagonists in the process of parturition, many women are still far from this ideal. They are rarely heard about what would bring them comfort or not at moment of their delivery. In this sense, the present study had as guiding question: what are the moments of comfort and discomfort experienced by the women during labor and delivery? With the purpose of answering this question, the objective was to analyze the experiences of comfort and discomfort of the women during labor and delivery.

LITERATURE REVIEW

The term comfort emerged as an object of research in three articles from this review, being described as a subjective experience that transcends the physical dimension as it also includes psychological, social, spiritual and environmental components, and can be considered a state of personal and environmental equilibrium⁸.

For this understanding, the theoretical reference of adopted in this research is that of Katharine Kolcaba's Theory of Comfort. This theory describes comfort as the satisfaction (active, passive or cooperative) of the needs for relief, tranquility and transcendence that emerge from situations that cause stress in health care in the physical, psycho-spiritual and sociocultural contexts. Nurses are responsible for identifying needs for comfort not met by other existing support systems and planning interventions to meet those needs⁹.

These professionals routinely identify and eliminate sources of discomfort before they affect the patients. Thus, the state of comfort can exist regardless previous discomfort. However, when discomfort cannot be avoided, it is usually mitigated with additional comfort, that is, through alleviating the discomfort⁹.

METHODOLOGY

This is a descriptive study with a qualitative approach carried out in three maternity hospitals in the city of Maceió-AL. Before initiating it, the formal consent of the participating institutions was obtained as well as the approval of the Research Ethics Committee of the Federal University of Alagoas under n^o 30777514.5.0000.5013.

In the period from July to September 2014, 40 puerperal women who were in the rooming-in ward of the maternity hospitals selected for the study were interviewed after signing the Informed Consent Term to express their agreement to participate in the study. Women who were 18 years of age or older who accepted to participate and who were physically and emotionally able to answer questions in the data collection instrument were included in the study; women who experienced natural childbirth with fetal death were excluded.

Data were collected through a semi-structured interview form composed of closed questions that allowed the characterization of the subjects (age, marital status, education, origin, religion and obstetric past; and also open questions, prepared with basis on the aforementioned theoretical framework, related to the experiences of comfort and discomfort of the women during labor and delivery.

An audio recorder was used to record the information present in the form, allowing for verbatim transcription for later analysis. Data saturation occurred when repetition was detected.

The analysis of the information obeyed the following steps: interviews' transcription, organization of collected data, pre-analysis by exhaustive reading of the texts produced, categorization and analysis of qualitative data. The analysis converged to the creation of two categories: experiences of comfort and experiences of discomfort¹⁰. In order to preserve the identity of the participants and the institutions, the puerperae were identified by the letters A, B or C (corresponding to maternities) and by the number of the chronological order in which they were interviewed.

RESULTS AND DISCUSSION

In this study, we interviewed puerperal women aged 18 to 41 years, with prevalence of those aged 20 to 29 years (62.5%); women living with their partners in consensual union (50%); with incomplete elementary school (40%); Catholics (37.5%); and from the countryside of the Alagoas and from the capital Maceió (47.5%). Two women were from other states. As for obstetric history at the moment of the interviews, most women reported having become pregnant only once (35%) and having experienced normal delivery for the first time (42.5%). Regarding miscarriages and cesarean sections, 8 and 5 puerperal women, respectively, reported having experienced such events.

Experiences of comfort

Through the analysis of the interviews, it was verified that the main experiences of comfort during labor and delivery reported by the puerperal women are the birth of the child (n = 24), the assistance provided by the health professionals of the maternity (n = 20) and the presence of a companion of their choice (n = 3).

The birth of the child was reported by most puerperae as a comfort during the parturition process. This experience was associated by the interviewees with the fact that they could see, hear or touch the child for the first time, as well as a sense of relief from the cessation of labor and delivery pains:

Delivery represents a crucial moment of transition in the motherhood since it provides the recognition between mother and child, promoting subsidies for the strengthening the affective bond. In this short time, the mother sees her baby for the first time, recognizing it as part of herself. Feelings of relief and happiness may arise associated with the overcoming of pain and fear and the reception of the child in her arms, as idealized during gestation¹¹.

The comfort at that moment, according to the conception in Katharine Kolcaba's Theory, arises from the satisfaction of the woman before the birth of the child, involving both physical and emotional aspects. The states of relief (condition of a person who has met a specific need satisfied), tranquility (state of calm and/or contentment) and transcendence (condition in which the individual overcomes his problems or suffering) derive from this experience⁹.

Providing care for women during labor and delivery should not be reduced to the development of techniques and procedures, but should mainly involve concern, interest, motivation, kindness, respect and consideration. Thus, the intention is to promote well-being, to keep women safe and comfortable, to offer support, minimize risks and reduce their vulnerability at that moment^7,12. In this sense, the assistance provided by health professionals in the maternity during labor and delivery appears as the second most frequently reported comfort among puerperal women.

"Humanizing childbirth means to give women what they are entitled to: a safe, welcoming and respectful care to their physical, emotional, psychological, social and spiritual needs, regardless of the professional who takes care of them or of the institution where they are" ^13:40.

In this sense, "an efficient, legitimate and quality nursing care must consider in its actions essential aspects such as dialogue, listening, touching, exchanging ideas, showing concern and expressing affection, as well as other holistic aspects of care"¹².

Support and care provided to women during labor and delivery are related to the Katharine Kolcaba's Comfort Theory that explains that, in stressful health care situations, comfort needs are met by nurses through the identification of needs that have not yet been satisfied by other support systems and through the planning of actions that can satisfy such needs ⁹.

Since 2005, the presence of a companion of the choice of women during labor and delivery under the Unified Health System (SUS) is guaranteed by Law 11,108, and is recognized as a practice that contributes to the humanization of delivery¹⁴, as can be observed in the speech of the puerperae:

According to the Ministry of Health, the benefit of the presence of the companion has already been proven. Several national and international scientific studies have shown that women who had the presence of companions felt safer and more confident during the delivery. There was also a reduction in the use of medications for pain relief, duration of labor and number of cesareans. Some studies also suggest the possibility of other effects, such as the reduction of cases of postpartum depression¹⁵.

The benefits of the presence of a companion comes from the emotional and physical support to the parturient, being inserted into the care process and allowing the women to have a family member close to them, especially because since the hospital environment is unknown to them. In this context, the comfort and encouragement provided by the companion allows the reduction of feelings of loneliness, anxiety and stress levels caused by the women's vulnerability at this moment of their lives¹⁶.

It is important to note that although the presence of the companion is confirmedly positive and guaranteed by law, many women are still prevented to have a companion during labor and delivery. Before with this reality, health professionals who provide care to women, including nurses, must overcome the barriers that impede the respect for this right and this way guarantee a humanized and quality assistance to parturients¹⁷.

Experiences of discomfort

The analysis of the interviews revealed that the main experiences of discomfort during labor and delivery reported by women are pain (n = 15), episiorrhaphy (n = 7) and increased pain from contractions due to the use of "serum" (n = 4).

Pain during labor and delivery involves biological, cultural, socioeconomic and emotional aspects, and should be understood in its broad aspect ¹⁸. This emerges as the most frequent discomfort reported by the puerperae, even when asked about other experiences of discomfort during labor and delivery.

Some pregnant women reported a negative expectation toward delivery, and the fear of feeling pain was of great relevance in this sense. After their experience, recalling the pain felt brings negative feelings and memories regarding this moment of motherhood. Thus, during provision of care for women in the process of parturition, health professionals should approach the women in order to understand what factors contribute to their stress and pain, by personalizing care and creating a trustworthy relationship that evidences the positive feelings brought about by delivery¹⁹ .

According to Katharine Kolcaba, nurses are judged based on the ability to keep patients comfortable. Therefore, it is up to these professionals and the other members of the team who work in the delivery to promote care in order to reduce the stressors and possible lack of preparedness on the part of the women, providing information and strategies that convey the necessary security and comfort, such as the use of non-pharmacological methods for pain relief^9,20.

The second most reported discomfort was the painful sensation described during the moment of suturation of the perineum, the episiorrhaphy, as well as to the discomfort caused by the presence of the suture line in this area:

Episiorrhaphy is uncomfortable due to the manipulation of the perineal area, which is very sensitive and becomes even more sensitive due to changes in labor and delivery. It also involves the emotional and doubtful sensations that the women experience at the moment, such as change in their genitalia, healing, sexual experience with their partners, issues that permeate the emotional state of these women, causing feelings of fear and physical pain²¹.

In view of this result, it is worth noting that the origin of the trauma (episiotomy or laceration) was not investigated in this study; however, in Brazil, episiotomy rates are higher than 76%, reaching 95.2% among nulliparous women. It is considered a routine intervention in most health services. According to the Ministry of Health, routine use of practices already considered obsolete by current evidence should be avoided by health professionals; only those validated by best scientific evidence available, combining art with science and aiming at a safe birth for mother and child, should be kept. The minimum of necessary interventions should be performed ¹⁶.

"Adequate care during childbirth is essential for the woman to have a safe and pleasurable experience, and it is essential that the health team adopt attitudes that facilitate the bond, and that they respect all the meanings of that moment, minimizing unnecessary invasive procedures"^21:2.

Because nurses are closer to the women at the moment, it is up to them to provide the best conditions to avoid a traumatic delivery, providing guidelines and methods that can prepare the perineum for the child to leave. In addition, providing support to the women during the suturation of the perineum should also be considered in cases when trauma cannot be avoided.

The exacerbation of pain caused by the use of "serum" was also described by women as a discomfort in labor and delivery. Unlike those who referred to pain as an isolated discomfort, these women blamed the "serum" for causing greater painful discomfort by intensifying contractions:

It is important to emphasize that the medical prescriptions were not investigated to analyze the type of substance present in the serum administered and the indication for its use, since the objective of this research was to investigate the woman's perception about comfort and discomfort during labor and delivery. However, it is possible to suppose that such discomfort was linked to the use of synthetic substances used to stimulate uterine contractility and consequently to accelerate labor, a common practice in the medicalized model¹⁶.

Both the unnecessary episiotomy and the unrestrained use of drugs that stimulate uterine contractility promoting the exacerbation of pain are against the proposed by the World Health Organization (WHO) on humanization of childbirth care. For the WHO, to humanize childbirth means to adopt a set of behaviors and procedures that promote healthy labor and delivery, respecting the natural process and avoiding unnecessary conducts or risks to mother and fetus¹⁷.

CONCLUSION

As seen through Katharine Kolcaba's Theory of Comfort, in stressful health care situations, the comfort needs are met by nurses. It is suggested, therefore, that nurses should understand the comforts and discomforts related to labor and delivery in order to make the humanization of care effective, providing alternatives so that the women feel comfortable and become the protagonists of this important moment in their lives.

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