id 15066

ORIGINAL RESEARCH

 

Episiotomy: feelings experienced by mothers

 

Janaina Pacheco VillelaI; Isabella de Souza Ramos da SilvaII; Elizabeth Rose Costa MartinsIII; Raquel Conceição de Almeida RamosIV; Cristiane Maria Amorim CostaV; Thelma SpindolaVI

I Nurse from the Universidade Veiga de Almeida. Rio de Janeiro, Brazil. E-mail: janaina.vill@gmail.com
II Nurse from the Universidade Veiga de Almeida. Rio de Janeiro, Brazil. E-mail: enfairamos@outlook.com
III Nurse. PhD in Nursing. Adjunct Professor, Faculty of Nursing, State University of Rio de Janeiro. Brazil. E-mail: oigresrose@uol.com.br
IV Nurse. Master in Nursing from the State University of Rio de Janeiro. Nurse at Policlínica Piquet Carneiro. Rio de janeiro Brazil. E-mail: raquel_rcar@msn.com
V Nurse. PhD in Nursing. Assistant Professor, Faculty of Nursing, State University of Rio de Janeiro. Rio de Janeiro Brazil. E-mail: cristiane.costa@ig.com.br
VI Nurse. PhD in Nursing. Associate Professor, Faculty of Nursing, State University of Rio de Janeiro. Brazil. E-mail: tspindola.uerj@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2016.21882

 

 


ABSTRACT

Objective: to learn the feelings and their impacts experienced by parturients who underwent episiotomy without prior knowledge. Method: this descriptive, qualitative study involved twelve women at an obstetrics unit in Rio de Janeiro city. Data were collected in March and April 2015 by semi-structured interview, submitted to content analysis and systematized into two categories: a deficit in clarifications to the women about episiotomy; and the impact of the women's feelings postpartum. The study was approved by the Ethics Committee (Opinion 950.963 and CAAE 39652614.8.0000.5279). Results: revealed a deficit in clarifications to the women about episiotomy, and the impact of the women's feelings postpartum. Episiotomies were performed without prior information or permission. Conclusion: there is suppression of information, and women's consent for the procedure is not being requested.

Keywords: Episiotomy; emotions; women's health; humanizing delivery.


 

 

INTRODUCTION

The object of this study is to know the feelings and repercussions of women who had undergone episiotomy without previous clarification during their stay in an obstetric unit in Rio de Janeiro.

The study emerged from the observation of pregnant, laboring and puerperal women in the visits performed to the maternity hospital during undergraduate course. During this period, postpartum women who had undergone episiotomy without previous guidance presented behavior of indignation, revolt and, in some cases, depression. Most of them were surprised by the difficulty in postpartum recovery and even in socializing with their baby. It was noted that the main complaint after the procedure was pain, fear and lack of information. Faced with this, these women ended up reporting labor exclusively as a moment of pain and violence.

Childbirth is one of the crucial moments in the life of women, in which health professionals are assistants, aimed at putting their knowledge at the service of the well-being of the woman and the baby, thus evaluating the critical moments in which their interventions must be necessary to ensure the health of both. In this process, health professionals can minimize pain, provide support, comfort, clarification, guidance and help1.

A study analyzing pain intensity in the postpartum period showed that women undergoing episiotomy or sutured lacerations reported more intense perineal pain than those with an intact perineum2.

Health professionals should participate in this process, performing their role with excellence and using their knowledge in order to clarify, guide and promote the physical and emotional well-being of the woman and the baby, in order to suppress myths and minimize feelings like pain and fear. However, they need to be aware of this responsibility by ensuring that procedures are favorable for the woman and the baby, not making unnecessary interventions and preserving, above all, women's privacy and autonomy.

An international evaluation of models of care revealed that countries that maintained a model of care for childbirth emphasizing respect for the physiology and dignity of women and their families and valuing the work of nurses, such as in England, Japan, the Netherlands, France, Germany and others, were able to keep their indicators of maternal and neonatal morbidity and mortality at low rates, as well as the index of interventions, such as cesarean sections and episiotomies3.

The submission of women to obstetrical routines, most of which are invasive, unnecessary and unknown, makes them an easy target for its consequences. Episiotomy is considered an aggressive procedure when performed without criteria, without appropriate indications and in a routine manner. Under these conditions, this procedure, that should be a facilitator in cases of obstetric urgency, becomes an example of disrespect and appropriation of the woman's body when not indicated.

In the face of these concerns, the following guiding questions emerge from the study: what was the feeling of these women when they realized they had been subjected to an invasive procedure without clarification and consent? What are the fears about performing episiotomy and the repercussions on their social and sexual life after the procedure? What is the greatest fear of these women, who had undergone this procedure, in postpartum recovery?

Based on these questions, the present study has as objectives: to know the feelings and repercussions experienced by the puerperal women who had been submitted to the episiotomy without previous knowledge hospitalized in the rooming-in of an obstetric unit located in the city of Rio de Janeiro; and discuss the feelings and repercussions experienced in the light of humanization of labor.

 

THEORETICAL REFERENCE

With the aim of making childbirth safer for both woman and baby, several technologies and procedures have been adopted in the hospital environment, thus improving indicators of maternal and infant morbidity and mortality. However, this advance allowed the emergence of a model that considers pregnancy, childbirth and labor as diseases, which exposes both the woman and her child to a large number of interventions, including episiotomy. These interventions, which should be used only in cases of extreme need, have become routine and reached many women in hospitals4.

Episiotomy is one of the most widely performed surgical procedures in the world, under the justification of reducing perineal lacerations during labor, preservation of female perineal muscles and sexual function, and the reduction of fecal and urinary incontinence. It has been said that when performed by means of a straight and clean incision it allows a better and faster healing when compared to a laceration. With respect to newborns, it is justified that episiotomy may reduce possible asphyxia, head trauma, cerebral hemorrhage and mental retardation1.

However, its adverse effects should be considered as extension of anal and rectal sphincter cut and lesion, unsatisfactory results such as skin folds, vaginal prolapse, anal fistula, hematomas, pain, infections, dehiscence, among others. Therefore, its routine use should be avoided1.

 

METHODOLOGY

This is a descriptive study with a qualitative approach that was submitted and approved in the ethics committee with the number of opinion 950.963. All requirements proposed by Resolution 466/12 of the Ministry of Health5 on guidelines and regulatory standards for research involving human beings have been respected.

The study scenario was an obstetric unit located in the city of Rio de Janeiro that has one maternal intensive care unit (ICU) with eight beds, one neonatal ICU with 20 beds, one delivery room with eight individual boxes, 36 beds for hospitalization of high-risk pregnant women, 24-hour obstetric and gynecological emergency care, one milk bank and 56 beds of rooming-in, where the data collection was performed. The subjects were 12 puerperal women in the age group of 15 to 35 years, hospitalized in the rooming-in of this institution. This age group was chosen because it is prevalent in labor in the unit. Inclusion criteria were puerperal women with verbal communication skills, with no complications at birth, and who had never had previous intervention. Participants signed a free and informed consent form, ensuring their anonymity. In this way, the participants received names of flowers randomly.

Data collection included the period from March to April 2015 and occurred through a semi-structured interview with the following questions: in many vaginal (normal) deliveries a cut is made in a small part of the vagina. Have you been guided about this procedure? If you have not been guided, how did you feel about it? What are your fears, doubts and/or feelings about your social and sexual life after this procedure? What is your biggest fear in postpartum recovery? The interviews were recorded and later transcribed for analysis. The data were submitted to content analysis6 and systematized into two categories: Deficit regarding women's understanding on episiotomy; and Repercussion of the feelings experienced by women in the puerperium discussed in the light of relevant literature.

 

RESULTS AND DISCUSSION

Regarding the obstetric history of the 12 puerperal women interviewed, all were of childbearing age, primiparous and had doubts and fears about maternity and puerperium. The age range of these women was 15 to 35 years. Ten (83.33%) puerperal women interviewed were single, one (08.66%) widowed and one (08.66%) married. Among the unmarried women, two were unaware about the baby's father, five have kept in touch with them and three had not report the pregnancy to the father. In Brazil, it is believed that almost all nulliparas are submitted to an episiotomy1.

The analyzes of the interviewees' statements revealed the need to categorize them according to the thoughts that summarize the knowledge of the episiotomy for the women regarding the participation in the decision of the procedure, the level of knowledge about the procedure and the repercussions of the feelings experienced by women in the puerperal period.

Category 1: Women's deficit of understanding on episiotomy

When they were asked about the prior knowledge on episiotomy, 11 (91.67%) of the interviewed women reported total ignorance about the procedure, knowing that they did not know why and how the procedure was done, which can be observed in the following lines:

I've never heard of that cut, chop [...] I do not know how you name it! (Daisy)

I did not even know it existed. It was a shock! (Violet)

No, I've never heard of it! (Bromelia)

It's a cut, right? For the baby come out easier. I think that's it ... (Orchid)

Daisy, Violet and Bromelia's lines highlight the lack of information about the procedure, as well as the disregard of the professionals who were responsible for these interviewees during prenatal and labor periods.

Women in the laboring period should be treated with respect, receive evidence-based information and be included in decision-making. For this purpose, professionals providing assistance should establish an open relationship with these women, understanding their desires and expectations. The practitioner needs to be aware of his or her actions, posture, tone of voice and how they provide care4.

As expected, most puerperal women (11) who answered that they did not know how the procedure was performed also did not know its indications.

I've never heard about the purpose [...] No, they haven't told me, no. (Pink)

They told me it was a cut, but not the purpose [...] I have even asked ... but you know things work, don't you? (Tulip)

They say the purpose is not to tear it apart [...] So, they cut for the baby comes out easier. (Azalea)

This study considers that the factors that contribute to a higher occurrence of episiotomy are nulliparity, prematurity and reduced vitality of the concept7.

Although it is one of the interventions most used nowadays in childbirth care in this study institution, only one (8.33%) puerperal women out of the 12 respondents answered that she was guided during the prenatal period, but she also could not explain, in fact, how the procedure was done and when it was indicated.

They told me I might need this cut, but they did not explain why, no ... (Dahlia )

An international study8 states that 34% of women who had undergone episiotomy reported that they were not consulted in decision-making and that 26% of women who had undergone episiotomy reported that they did not participate in the decision-making process and did not even receive information about this procedure.

This highlights the lack of information about the method used and its indications by the women who had undergone this procedure. This ignorance is understood as an act of power between health professionals and the empowerment of the female body, thus excluding the woman from the decision-making moment for considering her incapable of knowing what would be good or bad for herself, resigning herself to the care offered.

The Humanization Policy highlights that the hegemonic model of labor and childbirth needs changes in the models of health care, a change in the hospital-centered and medical culture, which should be centered in the needs and desires of these women and their relatives. For this purpose, there must be a change in the health professionals' posture to respect the physiology of childbirth and avoid unnecessary interventions such as routine episiotomy1.

Since most women are unaware of the physiology of their body and their unique abilities, they passively accept this domination by the professional, excluding their wishes and preferences, being increasingly unaware of their rights.

Based on a philosophy of care that should emphasize care practices based on scientific and cost-effective evidence, routine episiotomy should be abandoned from current obstetric practice1.

Category 2: Repercussion of feelings experienced by women in the puerperium

The feelings involved in the delivery/puerperal period by women who had undergone episiotomy without guidance and decisive participation at the time of delivery included indignation and doubts of various etiologies. When we asked how they felt after the childbirth, these women had practically the same answers and behaviors.

I don't know, I'm confused! I'm not sure about what happened. (Jasmine)

I feel much pain [...] I'm afraid to go home. (Azalea)

I wish I could go home, but I do not feel safe [...] I can get an infection, right? (Tulip)

I am afraid [...] Very afraid! (Daisy, Rose)

What do I have to say? Disrespect! [...] I've felt disrespected and had to accept it... to be silent! (Camellia)

It can be observed in the words of Azalea, Daisy and Rosa that the word "fear" is frequent. The lack of transmission of information by the professionals involved in the gestational, puerperal and gestational periods is responsible for this repercussion in the psychosocial context of these women, leading them to a situation in which they are submitted to frailty. However, this could have been changed through a little more carefully when we refer to the participatory role of professionals in this phase of life, in which the woman is frail and involved by doubts and fears.

Episiotomy may cause unpleasant sensations of pain, discomfort and shame of the appearance of her genital area, thus arousing fear of resuming sexual activity with her partner, causing insecurity and rejection9.

According to the interviews, the greatest fear of the puerperal women was related to the surgical points of incision, hygiene and sexual intercourse after the puerperium.

They haven't explain anything to me! I do not know what to do with these stitches, I do not know how to clean them ... (Amaryllis)

I'm afraid the stitches will open. (Orchid, Camellia, Tulip)

I'm scared even to go to the bathroom [...] I feel they can burst ... (Lily, Jasmine)

I told my husband that I will not feel safe to have relations with him for a long time [...] It must hurt, right? Because of the stitches ... (Dahlia)

The participation of professionals in this period was not as the expected at the informational level, even though they exert a great influence in the construction of the way of thinking and acting of a society, but they do not have this awareness when they address the educational context in health as unimportant.

It is understood that nursing care at the prenatal, labor and puerperal period go beyond the set of techniques, procedures and knowledge used by nurses. It is necessary that the professional understands this period in a physiological, humanized and comprehensive way, respecting the corporal and psychological integrity of the women and offering comfort, safety and quality of the assistance provided.

A study10 points out the importance of attending a laboring woman in a humanistic way, allowing the woman to experience some feelings, such as respect for her femininity, freedom of expression, safety and courage.

There is the need to transform mistaken professional practices instituted in a context of strong submission of women to biomedical knowledge. Although there is no concrete evidence for or against, practices such as routine episiotomy are still dominant in public and private services11.

It is important that health professionals form a broader thinking for the concept of humanization. In order for humanized assistance to be provided, the professional must include, in addition to their knowledge and skills, their moral and ethical principles towards the puerperal woman, incorporating in their assistance behaviors that above all provide safety so that the woman is attended to in all her needs, leading her to an excellent experience in natural delivery.

 

CONCLUSION

Episiotomy fits into an invasive and often aggressive context, which can generate fear, insecurity, revolt and other feelings in the puerperal woman, making her more vulnerable and submissive to the decisions of the health team, which leads her to assume a posture of acceptance even without knowing what is being done. This lack of questioning of women entails a natural resignation of the professionals in their service, thus repeating the same conduct.

It can be seen in this study that almost all women interviewed were unaware of episiotomy, its indications and purposes.

Most interviewees reported not having received any previous information about this procedure, having been subjected without guidance and without opportunity of intervention in the moment of decision. Through the interviews, we can see that women had not been guided during prenatal care, and not even during the delivery/puerperal period, and after the procedure, they remained with no information, full of doubts and fears. In these cases, it is evident that professionals involved had been negligent, omitted information, in addition to not having considered the request of informed consent to women.

This study evidenced that the decision on episiotomy is based on the authority exercised by obstetrical professionals, leaving aside any will and feeling of the parturient for or against the procedure. The women's opinion has not proved to be significant at the time of childbirth, since her human, bio-social, psychological, bioethical and sexual/reproductive rights, which are essential for the strengthening of women's opinion and their decision power, are seen with little or no importance by professionals.

The approaches made in this study about the sensations, repercussions and feelings of women submitted to episiotomy without guidance, information and participation in the decision-making of the birth lead to complications in the mediate and immediate postpartum, impacting on their social and sexual life.

It is essential that health professionals respect the physiology of women, not only in the pregnancy-puerperal period, but as an integral being, endowed with responsibilities and strengthened by female opinions, right to sexual and reproductive health, and who can and should express and demand respect for their decisions. The strengthening of women's opinion and decision power will take place from the moment woman is seen as a singular being whose decision-making rights are preserved and respected by the health team.

It is believed that nursing has an essential role in modifying the panorama of women's health and care to the pregnant, parturient and puerperal woman. With this, it is necessary to redirect the focus of nursing care so that we can act mainly in the education, prevention and health promotion of these women, always considering and attaching total importance to the autonomy and feelings of the female universe. It is believed that this research can contribute by encouraging a significant change in the posture of the obstetric team, making the woman-professional relationship more symmetrical and healthy. It is important to highlight that there are limitations in the research regarding the small number of women interviewed in the study, which did not allow inferences.

 

REFERENCES

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2. East CE, Begg L, Henshall NE, Marchant PR, Wallace K. Resfriamento local para aliviar a dor do trauma perineal sofrida durante o parto. Data Cochrane Syst Rev. 2012;5(5):CD006304.

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