id 15066

ORIGINAL RESEARCH

Invasive procedures in midwifery care from a gender perspective

Octavio Muniz da Costa Vargens^I; Sonia Nunes^II; Carla Marins Silva^III; Jane Márcia Progianti^IV

^I Obstetric Nurse. PhD in Nursing. Professor of Nursing at the Nursing Faculty of Rio de Janeiro State University, Brazil. E-mail: omcvargens@uol.com.br
^II Obstetric Nurse. Graduate student in Nursing, Faculty of Nursing, State University of Rio de Janeiro. Nurse at the Fernandes Figueira Institute/Fundação Oswaldo Cruz. Rio de Janeiro, Brazil. E-mail: sonian_u_n_e_s@yahoo.com.br
^III Obstetric Nurse. PhD in Nursing. Adjunct Professor of Nursing at the Nursing Faculty of Rio de Janeiro State University, Brazil. E-mail: carlamarinss@hotmail.com
^IV Obstetric Nurse. PhD in Nursing. Associate Professor of Nursing at the Nursing Faculty of Rio de Janeiro State University, Brazil. E-mail: jmprogi@uol.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.15066

ABSTRACT

Objective: to reflect on the use of invasive and painful obstetric procedures from a gender perspective in women's health. Method: it is a reflection developed from studies on labor pain, found in the bases: LILACS, MEDLINE and SciELO. The search comprised the period from 2005 to 2015. The inclusion criteria were reports of qualitative studies in Portuguese, the content of which had statements from women about the pain experienced during childbirth. We analyzed 27 statements from the 11 selected studies. Results: it was identified as the central thematic group 'unequal gender relations manifested through painful procedures', permeating relations of power and care for the parturient. Conclusion: when the interrelationships are of domain/submission, the parturients, unconsciously and involuntarily, assimilate the values and the worldview of the professionals becoming complicit in the established order.

Keywords: Obstetrical nursing, pain, gender, labor.

INTRODUCTION

Considering the studies carried out on causes and physiology, it is known that the labor pain reported by the parturients has variable intensities and is subjective^1-4. It is even observed that, for some mothers, the pain of childbirth can be in a moment of great suffering and soon thereafter cause of happiness given the awareness of being able to place someone very dear into the world⁵. However, in certain cases, this same pain can be reduced or increased depending on the procedures and techniques used directly on the parturient. It is interesting to observe that in the maternities many obstetric procedures are desired and requested by the parturients themselves. This fact finds answer in the affirmation that the medicalization acts in different sectors of the social life of the people, teaching them to desire certain therapies⁶. This desire, on the other hand, seems to have its origins in various forms of domination.

Issues such as gender in the women's health area are of paramount importance in the various aspects of improving the quality of the childbirth care⁷. A domination target, the women in labor, when preparing to receive their children, many times are not capable to react to some commands, practices and orientations to which they are submitted in the preterm delivery and delivery rooms, much less of defending themselves⁸.

In this context, the pain referred by the woman in labor is caused by factors other than physiology. Psychological and sociocultural factors and some relational aspects may contribute to an exacerbation of this pain, with special emphasis on gender relations⁹.

It is intended to reflect on the following question: how can the use of invasive and painful obstetric procedures during labor and childbirth be an instrument for strengthening unequal gender relations?

Thus, the present study aims to reflect on the use of invasive and painful obstetric procedures from a gender perspective in women's health.

METHODOLOGY

It is a reflection developed from studies on the pain of childbirth. For the purposes of this study, searches were conducted in the following databases: Latin American and Caribbean Literature on Health Science (LILACS), International Literature on Health Sciences (MEDLINE), and Scientific Electronic Library Online (SciELO).

Based on the consultation on the Health Sciences Descriptors (DeCS - VHL) website, the descriptors pain, labor and gender, associated with the childbirth descriptor, were used as the starting point for the search.

The inclusion criteria were: qualitative studies in Portuguese that had in their content testimonials of women about pain during labor. The search comprised the period from 2005 to 2015.

In all, 998 articles were found, however, 11 studies that were in agreement with the inclusion criteria were selected. Of these studies, 27 statements from women found in the texts were extracted.

The process of developing the analysis consisted of the following steps:

Selection of the texts to be analyzed according to the inclusion criteria;
Reading and analysis of the whole of the selected studies regarding: theoretical framework adopted, methodological procedures, results, context of the statements extracted;
Selection and extraction and analysis of the statements of the selected studies informants, according to the precepts of the thematic content analysis.

The extracts of the testimonies contained in the articles analyzed are identified in the text as direct quotations of the articles from which they were extracted.

RESULTS AND DISCUSSION

The analysis of the testimonies extracts contained in the texts allowed us to identify as central thematic group 'the unequal gender relations manifested through painful procedures', permeating the relations of power and care to the parturient and the perspective of humanization as a reduction of inequality of genre.

Unequal gender relations manifested through procedures

The gender issue has developed as an analytical category since the 1980s with the strengthening of the feminist movement. In gender studies, we find that its concept presents two propositions: Genre is an element composed of social relations based on perceived differences among the sexes. Gender is also a first way of signifying the relations of power¹⁰. When reflecting on power, it is necessary to first understand that power is not [only] located in the State apparatus and that nothing will change in society if the mechanisms of power that function outside the State apparatus are not modified. It can be understood that power is not something that is acquired, snatched or shared, something that is kept or let slip. Power is exercised from innumerable points and amid unequal and mobile relations¹⁰.

Gender relations in women's health are imbued with the power of the male professional as well as the knowledge of biomedicine. Over the centuries, the knowledge of biomedicine has been propagating to determine almost all practices that are part of maternal and child care¹¹. What once belonged to the daily practice of the woman and mother in her own residence accompanied by midwives, was gradually transferred to the hands and power of the physician. Several techniques for the delivery care with interventional characteristics have been adopted by the physician, such as cesarean section, forceps, episiotomy, epidural analgesia and spinal analgesia¹².

It is observed that the biomedical practice became sovereign, basically establishing itself through the strengthening of gender relations in women's health, which consequently led to the establishment and perpetuation of interventionist practices. The power previously exercised by the pregnant woman herself when giving birth to her child alone in the residence, with her relatives or with the midwife, was removed and handed over to the medical professional in hospital institutions¹³.

Other characteristics of domination proper to gender relations in health can be detected in the speeches of women in labor and delivery, when undergoing invasive procedures and intervention during the childbirth ¹⁴. In the present study, it was possible to identify some invasive procedures as representative of this unequal relationship and emphasize the use of a venous infusion of oxytocin, the performance of vaginal touch and the episiotomy.

The "serum"

Many parturients, when entering the preterm or delivery room are immediately submitted to a venipuncture for the installation of venous hydration with the addition of oxytocin¹¹. This medication is intended to accelerate or induce labor. Its action is immediate on the uterine musculature and causes it to present more frequent contractions. This fact consequently produces the increase of the pain in the parturient, but she by ignorance or fear, does not pronounce against it and accepts the installation of the serum^15,16.

[...] it was when the doses of serum were increased, I think it is to try to dilate more, it was very painful, I think it is a normal process(M-9)^15:110.

The serum is horrible... but it helps because with no dilation it does not happen. (Violeta)^16:309.

Most parturients when arriving at the maternity wards already know the "serum" story. This information is obtained from women of the family and from those multiparous women who during the prenatal care were partners in the waiting room of the consultations. It seems that they are already reaching the hospitals aware of the "importance" of the serum and, especially, of the need for acceptance of obstetric behavior.

During labor I was walking, and it made me want to pee. Then, the doctor said: 'Gee, you're messing with the serum. You have to take the serum carefully '. But the serum didn't help much, because it was stopped for a long time and nobody noticed. So, I took the serum, but the doctor [professional who was with her at the time] said: 'careful mom, so you don't mess up the serum. I'm alone' (Dália ^16:309.

It is observed in the following testimony that the process of medicalization and domination of the woman's body by doctors caused some of them to accept and believe that the performance of invasive procedures would be beneficial for the evolution of the childbirth, even ifin some cases it was also the main cause of the exacerbation of pain and suffering.

I was worried about the serum that increases the pain. If the serum was not here, I wouldn't be feeling so much pain. But deep down I knew that the serum was helping (Rosa)^16:309.

Regarding the childbirth mechanisms, the obstetric nursing values the preservation of the physiology of the organism and uses non-invasive technologies of nursing care, avoiding the administration of oxytocin to the parturient. It is known that when presenting the contractions, the gravid uterus at the end of gestation is working naturally to expel the fetus that already is, according to this same physiology, at its moment of birth¹⁷. Oxytocin, a substance produced by the hypothalamus, is responsible for promoting the contraction of the uterine musculature. However, medical conducts lead to the regular prescription of oxytocin serum to accelerate the delivery, among other factors¹². In this case, the serum becomes a factor of invasion and interference of the mechanisms proper to the body's physiology during labor and childbirth.

The "touch"

Another invasive procedure that causes pain and disturbs the woman is the vaginal touch. The vaginal touch disturbs the parturient not only due to the bodily invasion, but also because of the frequency of the examination and the way it is performed.

[…] they treat us like it's normal to feel pain, then it's normal to feel pain, if you talk, [...] so if you scream, they make you shut up, so everything is normal […] (m13)^15:109;

[...] There's no right side, there is no way to be, you keep turning back and forth, the annoyance of the touches, it bothers a lot, it's absurd. No, I don't know what to say. I didn't know that it could be natural. I don't know it ranges if it was natural, maybe yes, maybe not [...] (m10)^15:109.

In practice, it is observed that many parturients right after the touch refer to a discomfort and to the increase of the pains of the uterine contractions. It is also clear that these examinations are often carried out grossly and with aspects of domination, imposition or indifference to the appeals and rights of the parturient. These attitudes are characteristic of gender relations:

It was bad because they have those [vaginal] touch exams, they [doctors] hurt us a lot, that touch exam is frequent, it's one after another, we do not want to have a child anymore because every time that touch exam is made we feel pain, then it seems that it gets worse [...] it hurts us [...] it was more than one [professional], two did the exam, one after the other [...] I felt bad during the exam part [...] I say they weren't aggressive, but rough [...] at least one scolded me because I was terrified about how many times they were examining me [...] I was very embarrassed and some people said that I did not stay still, but I tried to collaborate [...] they changed their tones [...] I think we have to talk and take it easy, do not just come and tell us to stay in one way if you do not explain what you're going to do to us. (16 years old primiparous)^18:147.

In the statement above, the medical professional often develops unnecessary and invasive procedures that themselves demonstrate a striking gender relationship, and which, in addition, are capable of interfering with the physiology of labor. On the other hand, the obstetric nursing in search for the implementation of non-invasive practices in childbirth care tries to develop with the parturient practices that are known and authorized by the pregnant woman herself.

The obstetric nursing is a profession composed basically of female professionals, aware of the importance of the historical relations of power and domination between doctors and parturients, it tries to assert their rights at the labor time^18,19. Their needs for freedom of choice of techniques and procedures whether they are invasive or not is mainly considered. It is observed that nursing seeks to develop with the women in labor and delivery a relation of respect and not of power or domination. In these cases, the gender relations with the parturient take place more democratically.

The "cut"

Another invasive procedure, often adopted without the knowledge or consent of the parturients, and characteristic of interventions in childbirth is the episiotomy. The sensation that the studied parturients had because of the episiotomy and episiorrhaphy are reported below.

Then, the worst part came, in my opinion, it was the time of suturing, I felt pain and a strange sensation when the line passed, very strange (E9)^20:47.

But what was more difficult for me was the time for the stiches. I thought they had cut up to the anus. The feeling I had was that it was all open, from so many stiches that they gave me. And the anesthesia did not really take in, so I felt every stitch, one by one, and just imagined the damage they had done to my vagina. (E7)^20:47.

There was the episiorrhaphy and that's when I noticed the procedure, because it hurt a lot, both at that time and after, and it bothered me very much to sit(E1)^20:47.

The most uncomfortable postpartum, besides the pain of the local cut that made it difficult to sit... (E2)^20:48.

An episiotomy is a surgical incision made in the perineum to protect your muscles from injury or bruising resulting from distention, and to prevent the pressure exerted by the fetal head for an extended period²⁰. For the obstetric nursing, however, this is an invasive procedure that provides pain and can lead to complications in the puerperium.

The perineal protection is a non-invasive obstetric nurse care technology that has been widely applied in maternity hospitals in Rio de Janeiro. When attending births, these professionals generally seek to preserve the integrity of the perineum by avoiding the episiotomy. When it is necessary to perform such a procedure, because it is invasive and a factor that favors local pain or complications, the parturient is informed avoiding, thus, the actions characteristic of gender relations as imposition of knowledge and domination of the professional's will above the client's¹⁷.

Humanization and support: reducing gender inequality

The proposal of humanization includes the reduction of gender inequality through the adoption of diverse practices and attitudes that respect women's autonomy and rights, as it is the use of non-invasive technologies of obstetric nursing care^21-23. The presence of a companion becomes a strategy for the humanization of labor and birth. By favoring this question, the team asserts the rights of the parturient and her family:

At this much-needed time, it is very good to have a companion by your side; here in the delivery house, the husband and the son are not really missed, because the attention of the nurses is great. (Ent. 10) ^17:269

At the time of labor and childbirth, the woman can perform better in the role of the birth of her child if she receives support and security from an accompanying person. The following report shows the importance of the presence of a professional who considers an attitude of respect for the rights of the parturient to be indispensable without being imputed to acts of power and domination.

[...]attention is everything. I thought that a woman, that a woman nurse treated the person badly ... but it was the opposite [...]. (Violeta)^16:310.

The report above also reflects the importance of parturients to give birth accompanied by female professionals and who show attentive, informative and humanized behavior.

Regarding the humanization of labor practices such as routine intravenous infusion in labor, administration of oxytocic before childbirth in a manner that is not allowed to control its effects, a liberal or routine use of episiotomy, frequent vaginal touches and by more than one examiner, Kristeller's maneuver or similar, with pressures inappropriately applied to the uterine fundus during the expulsive period, are considered by the Ministry of Health to be harmful or ineffective and must be eliminated²⁴.

On the other hand, the Ministry of Health is in favor of attitudes and practices that stimulate the event of a humanized childbirth. Among these, we highlight some that are demonstrably useful and that should be encouraged: respect for the woman's choice about the place of childbirth; respect for the woman's right to privacy at the place of childbirth; emotional support by service providers during labor and childbirth; providing women with all the information and explanations they desire; use of non-invasive and non-pharmacological methods of pain relief, such as massages and relaxation techniques during labor²⁴.

These strategies of care also provide the parturient with respect for her status as the real protagonist of the childbirth because her will and rights are not being stifled or invalidated by unequal gender relations.

CONCLUSION

It is possible to conclude that characteristic aspects of gender relations were implicit in the interviews obtained from the articles analyzed. It is observed that the gender relations in the field of women's health reproduce the paradoxical logic of male domination and female submission verified in the civilization as a whole and that the use of invasive and painful obstetric procedures are strengthened by the same relationship of domination and increased by medicalization.

It was also observed that in the social relations in which the interrelations are dominion/submission, the dominated, unconscious and involuntarily, assimilate the values and worldview of the dominant and thus become accomplices of the established order without realizing they are the first and main victims of that same order. They submit to the procedures.

In this sense, it is necessary to promote the rupture of the vicious circle that perpetuates the acceptance of differences as something natural, whether they are social, economic or gender related, in order to comply with the principles of humanization defended by SUS, especially regarding the care of women in labor.

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