PUERPERAL W OMEN’S PERCEPTI ONS ON VERTI CAL AND HORI ZONTAL DELI VERI ES
1Mich ele Edian ez Gay esk i2 Odaléa Mar ia Br ü ggem an n3
Gay esk i ME, Br üggem ann OM. Puer per al w om en’s per cept ions on v er t ical and hor izont al deliv er ies. Rev Lat ino-am En fer m agem 2 0 0 9 m ar ço- abr il; 1 7 ( 2 ) : 1 5 3 - 9 .
This qualit at ive st udy aim s t o bet t er under st and t he per cept ions of puer per al w om en r egar ding t heir exper iences
in ver t ical and hor izont al deliver ies and ident ify posit ive and negat ive aspect s of each posit ion. Sem i- st r uct ur ed
int er view s w er e car r ied out w it h t en puer per al w om en hospit alized in t he r oom ing- in unit of a t eaching hospit al.
Af t er t h em at ic an aly sis – Collect iv e Su b j ect Discou r se – p osit iv e asp ect s of t h e v er t ical p osit ion em er g ed ,
nam ely: gr eat er com for t , fr eedom of m ovem ent , r educt ion of t he expulsive effor t , favor s w om en’s par t icipat ion.
Negat ive aspect s w er e list ed as discom for t and lack of obst et r ic int er vent ion. Posit ive aspect s of t he hor izont al
posit ion w er e r epor t ed as quickness, feelings of secur it y and of being helped. Negat ive aspect s w er e r elat ed t o
discom for t and difficult y in ex er t ing st r engt h. Posit iv e aspect s of t he v er t ical posit ion and negat iv e aspect s of
t he hor izont al posit ion st ood out m or e int ensely and fr equent ly, and ar e in accor dance w it h scient ific evidence.
DESCRI PTORS: par t ur it ion; labor st age, second; hum anizing deliv er y ; qualit at iv e r esear ch
PERCEPCI ONES DE PUÉRPERAS SOBRE LA VI VENCI A DURANTE EL PARTO EN LA
POSI CI ÓN VERTI CAL Y HORI ZONTAL
Se t r at a d e u n est u d io cu alit at iv o, cu y o ob j et iv o f u e con ocer las p er cep cion es d e las p u ér p er as sob r e la
v iv encia del par t o en la posición v er t ical y hor izont al, ident ificando los aspect os posit iv os y negat iv os de cada
posición. Fuer on ent r ev ist adas 10 puér per as en el aloj am ient o conj unt o de un hospit al univ er sit ar io. Después
del análisis t em át ico – Discur so del Suj et o Colect ivo – em er gier on los aspect os posit ivos de la posición ver t ical:
m ás cóm oda; favor ece la m ovilidad y r educe el esfuer zo de expulsión; favor ece la par t icipación de la par t ur ient a;
siendo la incom odidad y la falt a de int er vención obst ét r ica apunt ados com o negat ivos. En lo que se r efier e a la
posición hor izont al, los aspect os posit ivos fuer on: el par t o es m ás r ápido, gener a segur idad y sensación de ser
ayudada y los negat ivos est uvier on r elacionados a la incom odidad y dificult ad par a hacer fuer za. Los discur sos
sobr e los aspect os posit iv os de la posición v er t ical y n egat iv os de la h or izon t al se dest acan de f or m a m ás
int ensa y fr ecuent e y est án congr uent es con las ev idencias cient íficas.
DESCRI PTORES: par t o; segundo per iodo del t r abaj o de par t o; par t o hum anizado; inv est igación cualit at iv a
PERCEPÇÕES DE PUÉRPERAS SOBRE A VI VÊN CI A DE PARI R N A
POSI ÇÃO VERTI CAL E HORI ZONTAL
Est u d o q u alit at iv o, cu j o ob j et iv o f oi con h ecer as p er cep ções d as p u ér p er as sob r e a v iv ên cia d e p ar ir n a
posição ver t ical e hor izont al, ident ificando os aspect os posit ivos e negat ivos de cada posição. For am ent r evist adas
10 puér per as no aloj am ent o conj unt o de um hospit al univer sit ár io. Após análise t em át ica – Discur so do Suj eit o
Colet iv o – em er g ir am os asp ect os p osit iv os d a p osição v er t ical: m ais côm od a; f av or ece a m ov im en t ação;
r eduz o esfor ço expulsivo; favor ece a par t icipação da par t ur ient e; sendo o desconfor t o e a falt a de int er venção
obst ét r ica apon t ados com o n egat iv os. Qu an t o à posição h or izon t al, os aspect os posit iv os f or am : o par t o é
m ais r ápido, ger a segur ança e sensação de ser aj udada e os negat iv os est iv er am r elacionados ao desconfor t o
e dif icu ldade par a f azer f or ça. Os discu r sos sobr e os aspect os posit iv os da posição v er t ical e n egat iv os da
hor izont al dest acam - se de for m a m ais int ensa e fr equent e e est ão congr uent es com as ev idências cient íficas.
DESCRI TORES: par t o; segunda fase do t r abalho de par t o; par t o hum anizado; pesquisa qualit at iv a
1
This r esear ch w as suppor t ed by Fundo de I ncent ivo à Pesquisa, FUNPESQUI SA, Univer sidade Feder al de Sant a Cat ar ina, Br azil, Pr oj ect # 1642007; 2Nur se-Midw ife, Hospit al Univ er sit ár io, Univ er sidade Feder al de Sant a Cat ar ina, Mast er ’s st udent , Univ er sidade Feder al de Sant a Cat ar ina, Br azil, e- m ail: m ichelegayesk i@hot m ail.com ; 3Nur se- Midw ife, Ph.D. Tocoginecology, e- m ail: [email protected].
I NTRODUCTI ON
I
n m o st ci v i l i za t i o n s, ch i l d b i r t h h a s b een perform ed wit h t he wom an in t he vert ical posit ion. Fromt h e 1 6t h ce n t u r y o n w a r d s, t h e l y i n g p o si t i o n w a s
a d o p t e d , p u t t i n g w o m e n i n a n a n t i - p h y si o l o g i ca l
posit ion, which cont ribut ed t o t he use of unnecessary
t echnology( 1).
Af t er t h e m ed i ca l i za t i o n o f ch i l d b i r t h , t h e
g y n ecol og i cal p osi t i on d u r i n g t h e ex p u l si v e p er i od
st art ed t o be considered t he m ost adequat e t o perform
healt hcare procedures and was adopt ed as a classical
p o si t i o n d u r i n g ch i l d b i r t h . As i n o t h e r o b st e t r i ca l
int ervent ions, t his posit ion was indiscrim inat ely adopt ed
w i t h o u t p r o p e r l y e v a l u a t i n g i t s e f f e ct i v e n e ss a n d
safet y( 2- 4).
Cu r r e n t l y, t h e Wo r l d He a l t h Or g a n i za t i o n
( WHO) recom m ends, based on scient ific evidence, t hat
par t ur ient s ar e not put in t he gy necological posit ion
d u r in g lab or an d d eliv er y b ecau se it is con sid er ed
harm ful and ineffect ive. However, every wom an should
be free t o choose her posit ion( 5).
Recen t ev id en ce sh ow s t h at t h e v er t ical or
lat eral posit ion, when com pared t o t he horizont al posit ion
( supine or gynecological) , reduces t he durat ion of t he
expulsive period, com plaint s of severe pain, num ber of
C- sect ions, t he need for episiot om y, and alt erat ions in
fet al heart beat . However, t he use of t his posit ion is relat ed
t o t h e in cr easin g n u m ber of secon d- degr ee per in eal
lacerat ion cases and blood loss of m ore t han 500 m l.
Considering t he risks and benefit s of different posit ions,
wom en should be allowed t o m ake inform ed decisions
on which posit ion t o adopt during delivery( 6).
I n general, m at ernit ies in Brazil st ill recom m end
t he horizont al posit ion during delivery and do not allow
wom en t o choose( 7), alt hough som e m at ernit ies st art ed
t o at t end deliv er ies in t he v er t ical or lat er al posit ion,
based on WHO recom m endat ions for childbirt h care( 8- 9).
The im plem ent at ion of non- supine posit ions in
t h e ex pu lsiv e per iod h as been on e of t h e ev iden
ce-based pract ices, which is part of t he t ransit ion from t he
car e m odel focused on t echnology t o one focused on
phy siology( 9). How ever, it is necessar y t o ver ify how
w om en h av e ex p er ien ced t h is ch an g e in ch ild b ir t h
posit ion so as t o evaluat e whet her wom en consider t his
pr act ice fav or able.
Th u s, t h i s st u d y a i m e d t o d i sco v e r h o w
puerperal wom en perceive childbirt h in t he vert ical and
hor izont al posit ions, ident ify ing posit iv e and negat iv e
aspect s of each posit ion during t he childbirt h experience.
METHOD
This is an explorat ory qualit at ive st udy, carried
ou t w it h pu er per al w om en at t en ded in t h e t each in g
hospit al at t he Federal Universit y of Sant a Cat arina ( HU/
UFSC) . Ten w om en w h o g av e b ir t h in v er t ical an d
horizont al posit ions were int erviewed in t he room ing- in
unit upon t heir hospit al discharge from Novem ber 2006
t o Febr uar y 2007. A sem i- st r uct ur ed int er view w it h a
t hem at ic script was used and recorded. The num ber of
puerperal wom en was est ablished during dat a collect ion
by infor m at ion sat ur at ion, t hat is, w hen infor m at ion
becam e r epeat ed.
Recor d ed in t er v iew s w er e f u lly t r an scr ib ed ,
checked and correct ed by list ening t o t he recordings a
se co n d t i m e . To o r g a n i ze d a t a o r i g i n a t e d f r o m
int erviews, Et hnograph version 5.0 soft ware was used.
Th r ou g h t h em at ic con t en t an aly sis, cen t r al
ideas and k ey ex pr essions w er e ident ified, based on
w h i ch t h e Co l l e ct i v e Su b j e ct i v e D i sco u r se w a s
const ruct ed. I t consist ed of a synt hesis, in t he first person
sin gu lar, of key- ex pr ession s, w h ich cor r espon ded t o
each Cent ral I dea. This m et hodological proposal for t he
organizat ion and t abulat ion of qualit at ive dat a is based
on t he assum pt ion t hat collect ive t hinking can be seen
as a set of discourses on a given t opic( 10).
The Research Et hics Com m it t ee at t he Federal
Un iv er sit y of San t a Cat ar in a appr ov ed t h e r esear ch
pr ot ocol ( No. 276/ 06) . Par t icipant s w er e infor m ed on
t he obj ect ives and t he research developm ent and agreed
t o p ar t icip at e t h r ou g h a w r it t en f r ee an d in f or m ed
consent t er m . Et hical aspect s ar e in accor dance w it h
Resolut ion 196/ 96.
The concept of v er t ical posit ion in t his st udy
refers t o childbirt h at t ended on an obst et ric t able wit hout
leg holders, which allows t he part urient t o squat at t he
m o m en t o f ex p u l si o n . Th i s p r act i ce w as g r ad u al l y
incorporat ed by t he ent ire healt h t eam at t he HU/ UFSC
m at ernit y, according t o wom en’s choice. I n t he horizont al
p osit ion , also d escr ib ed as g y n ecolog ical or su p in e
posit ion, t he part urient is put in gynecological posit ion
w it h an k les su ppor t . I n in t er n at ion al lit er at u r e, t h e
v er t ical posit ion is classif ied as n on - su pin e an d t h e
horizont al one as supine( 6,11).
RESULTS AND DI SCUSSI ON
So ci o d em o g r a p h i c a n d o b st et r i c ch a r a ct er i st i cs o f
I nt er view ed w om en w er e bet w een 20 and 37
y ear s old, four w er e m ar r ied and six w er e in st able
u n i o n s, n i n e w er e w h i t e an d o n e w as b l ack . Wi t h
r egar d t o schooling, four had com plet e pr im ar y school
an d t w o h ad in com p let e p r im ar y sch ool; t h r ee d id
not com plet e secondar y school and one w as at t ending
c o l l e g e . S i x w o m e n h a d p a i d w o r k , t h r e e w e r e
housew iv es and one w as a st udent . Regar ding par it y
an d p ar t icip at ion in ed u cat iv e act iv it ies d u r in g t h e
pr enat al per iod, six w er e secundipar a ( G2P2) and four
w er e m ult ipar a ( G4P4 - t w o; G5P4 - one; G5P3 – one) ;
t hr ee had not par t icipat ed in any lect ur e for pr egnant
w om en , six p ar t icip at ed in b et w een on e an d t h r ee
and one in eight lect ur es.
Of t h e t en i n t er v i ew ed p u er p er a l w o m en ,
eight w ere accom panied by t heir husband in t heir last
deliver y; one w as accom panied by her sist er and only
one had no com panion. All gav e bir t h in t he v er t ical
posit ion in t he last delivery and t he one before w as in
t h e h or izon t al posit ion . All n ew bor n s fr om t h eir last
deliv er y w er e full- t er m w it h no clinical int er cur r ence
t hat indicat ed hospit alizat ion in t he neonat al int ensive
t her apy unit .
Po si t i v e a sp ect s r eg a r d i n g v er t i ca l a n d h o r i zo n t a l
posit ion s du r in g deliv er y
Cen t r al ideas t h at em er ged f r om in t er v iew s
w it h puer per al w om en ex pr essing posit iv e aspect s of
d el i v er i es i n v er t i ca l a n d h o r i zo n t a l p o si t i o n s a r e
pr esent ed in Table 1.
Table 1 – Puer peral w om en’s cent ral ideas on posit ive
asp ect s of v er t ical an d h or izon t al p osit ion s d u r in g
deliv er y. Flor ian ópolis, SC, Br azil 2 0 0 6 - 2 0 0 7
s t c e p s A e v i t i s o P -s a e d I l a r t n e C n o i t i s o p l a c i t r e
V HorizontalPosition
e r o m s i n o it i s o p l a c it r e v e h t -1 I C e s l u p x e o t t s e t s a f d n a e l b a t r o f m o c y b a b e h t g n i r u d r e t s a f s i y r e v il e D -7 I C e h t o t e u d n o it i s o p l a t n o z i r o h y m o t o i s i p e o t r e e r f s l e e f t n e i r u t r a p e h T -2 I C n o it i s o p l a c it r e v n i e v o m n o it i s o p l a t n o z i r o H -8 I C y t i r u c e s f o g n il e e f e h t s e t a r e n e g " d e p l e h " g n i e b f o d n a , n o it i s o p l a c it r e v g n i r u D -3 I C , d e t c e r i d r e t t e b s i h t g n e r t s t r o f f e g n i c u d e r e r o m s i n o it i s o p l a t n o z i r o H -9 I C e l b a t r o f m o c s e t a p i c it r a p t n e i r u t r a p e h t -4 I C h t r i b e h t h c t a w o t e l b a s i d n a e r o m n o it i s o p l a c it r e v g n i r u d y b a b e h t f o s i y r e v o c e r m u t r a p t s o P -5 I C n o it i s o p l a c it r e v e h t n i r e t s a f d e c u d e r s i n i a p k c a B -6 I C
Posit iv e aspect s on t he v er t ical posit ion ar e
r e l a t e d t o t h e se n sa t i o n o f co m f o r t , f r e e d o m o f
m ov em en t , r ed u ced ex p u lsiv e ef f or t an d p ain , an d
w om en’s m or e act iv e par t icipat ion. On t he cont r ar y,
p o s i t i v e a s p e c t s o f t h e h o r i z o n t a l p o s i t i o n a r e
charact er ized by int er vent ions, especially episiot om y,
feeling of being “ helped” and com for t by t he possibilit y
of ly ing dow n. The m ost im por t ant cent r al ideas ar e
h e r e i n d i scu sse d w i t h t h e i r r e sp e ct i v e Co l l e ct i v e
Su b j ect Discou r se ( CSD) .
CI 1 – Ver t ical posit ion is m or e com f or t able, easier
and fast er t o ex pulse t he baby
Squat t ing is bet t er for deliver ing ( ver t ical posit ion) , it w as m uch fast er [ ...] t he effor t w e exer t , it com es out fast [ ...] it is not for ced as in t he lying posit ion, w hich som et im es t akes longer, t hen t hey have t o cut us... lying down is difficult . Squat t ing is m or e com for t able, easier ; you don’t fall dow n or t ur n because you’r e suppor t ed [ ...] . The ot her posit ion ( hor izont al) is lying down wit h your legs up. I didn’t like t his posit ion, I liked squat t ing bet t er [ ...] t he body’s nat ur e asked m e t o sit , lying dow n w ould hur t m or e. The advant age of squat t ing is t hat it w as nat ur al t o sit t o have t he baby ( CSD 1) .
Of t he 20 clinical r andom ized t r ials analy zed
in a syst em at ic review on posit ions in t he second st age
of labor, nine appoint ed r educed durat ion of t his st age
w h en t h e p ar t u r i en t assu m es n o n - su p i n e p o si t i o n
( l a t e r a l o r v e r t i c a l ) c o m p a r e d t o s u p i n e o r
g y n e c o l o g i c a l p o s i t i o n( 6 ). CS D 1 ’ s t e s t i m o n y
ex em p l i f i es h o w w o m en p er cei v e r ed u ct i o n o f t h e
ex pu lsiv e per iod, w h ich im pr ov es t h eir ex per ien ce.
Pelv ic dim ensions ar e significant ly ex panded
in vert ical posit ions and increased efficiency of ut erine
cont r act ions also occur because t he aor t a ar t er y and
v ena cav a ar e not occluded, w hich fav or s labor and
deliv er y. I t also favor s t he par t ur ient ’s per cept ion on
t h e g r ad ien t of in cr easin g u t er in e con t r act ion s an d
incr eased pr essur e on t he per ineum ( 1).
On t he cont rar y, accor ding t o t he CSD of t he
CI 7, t he feeling t hat t he delivery is fast er is associat ed
t o m edical int er v ent ions, especially t he episiot om y.
CI 7 – The delivery is fast er in t he horizont al posit ion
due t o t he episiot om y.
once, t w ice, t hr ice and t hen t her e’s a t im e you have no st r engt h anym or e and [ …] oh! t hey let it t ear ( CSD 7) .
I n a s t u d y o n t h e p e r c e p t i o n o f w o m e n
r egar ding episiot om y, t he m aj or it y of t hem r epor t ed
it s need so as t o have t he labor channel expanded t o
av oid r isks t o t he baby, since t he vagina cannot ext end
it self( 12).
Episiot om y is a sur gical pr ocedur e gener ally
p er f or m ed d u r in g ch ild b ir t h in Lat in Am er ica, w h ile
it s u se is r ed u ced in Eu r op ean cou n t r ies( 1 3 ). Br azil
pr esent s high rat es of episiot om y, w hich is per for m ed
i n ap p r ox i m at el y 9 4 . 2 % of n or m al d el i v er i es( 2 ). I t
con t r ibu t es t o t h e “ n at u r alizat ion ” of t h e pr ocedu r e
because it m ak es som e w om en consider t his m edical
int er v ent ion, oft ent im es unnecessar y and r out inely( 5)
u sed , as som et h in g p osit iv e t h at h elp s t o en d t h e
deliv er y f ast er.
CI 3 – St r en g t h i s b et t er d i r ect ed i n t h e v er t i ca l
posit ion, w hich r educes effor t
The posit ion helps us t o exert st rengt h, it ’s m uch easier [ …] you m anage t o direct your st rengt h t o your legs. I ’m not very agile in cr ouching dow n and get t ing up [ …] so I t hought I ’d have cr am ps, but I had no pr oblem at all, I felt m or e com for t able. I t ’s bet t er even for you t o exer t your st r engt h because, in t he ot her ( hor izont al posit ion) , you have no w ay t o suppor t your feet , your legs are dropped down. I n t his one ( vert ical posit ion) you support your feet and it seem s ever yt hing w or ks fast er . The squat t ing has sever al advant ages: it ’s t he posit ion, t he gr avit y, it ’s less painful, [ …] the labor is very painful, but at the m om ent of expulsion it was easier, so I see advant ages in squat t ing ( CSD 3) .
Ther e is a dim inished feeling of int ense pain
dur ing t he ex pulsiv e per iod in t he v er t ical or lat er al
posit ion w hen com par ed t o t he supine or gynecological
posit ion( 6 ). Th e per cept ion t h at t h e v er t ical posit ion
cont r ibut es t o exer t st r engt h and expel t he fet us due
t o gr av it y w as also descr ibed in an ot h er qu alit at iv e
st udy. How ever, in t his case, professionals considered
t h e p a r t u r i e n t w a s b e i n g r e b e l l i o u s b e ca u se sh e
in sist ed on bein g k ept in t h is posit ion an d con f in ed
her t o t he deliver y t able( 14).
CI 4 – Th e par t u r ien t m an ages t o par t icipat e m or e
and w at ches t he birt h of her child in t he vert ical posit ion
List en ! I t h in k t h at , in t h is ( v er t ical d eliv er y ) w e par t icipat e m or e [ …] t he nur se only helped m e w hen t he child w as com ing out , pulling t he lit t le head from one side t o t he ot her. I did t his m yself [ …] you see ever yt hing, you see t he child. On
t he one fr om m y fir st daught er I didn’t see anyt hing, t hey t ook her fr om t her e, t ook her t o t he doct or s’ pr ocedur es, t hen t hey br ought m e t he gir l. And t her e ( ver t ical posit ion) you can see ever yt hing. So I t hink t hat for t he m ot her it ’s m or e t hr illing, y ou see w hen t hey cut t he cor d [ …] I could see ever yt hing, so I liked it ver y m uch ( CSD 4) .
Th e v er t ical ch ildbir t h f av or s t h e par t u r ien t ’s
p a r t i ci p a t i o n , e a se s t h e o b se r v a t i o n o f co n d u ct s
per f or m ed an d v isu alizat ion of t h e bir t h , w h ich ar e
f act or s em ot ion ally im p or t an t t o en ab le a p osit iv e
e x p e r i e n c e i n l a b o r. T h e s a t i s f a c t i o n w i t h t h e
deliv er y can be in cr eased if w om en h av e t h e opt ion
t o ch oose t h e posit ion of deliv er y( 1 1 ). How ev er, CI 8
r ep o r t s t h at t h e h eal t h p r o f essi o n al ’ s act i v e w o r k
d u r in g t h e at t en d ed b ir t h is p osit iv e w h en w om en
ex pect t h em “ t o h elp” an d t r an sf er r espon sibilit y t o
t h e m .
CI 8 – The hor izont al posit ion gener at es secur it y and
feeling of being “ helped”
I t hink t hat lying dow n you feel safer , it seem s t he pr ofessional helps you m or e. I n t he hor izont al posit ion I had a com panion and in t his one I had nobody [ ...] I didn’t have a com panion and felt really alone. So, I felt safer when people were t here accom panying m e because even when I had t o exert st rengt h t hey helped m e m or e and, in t he squat t ing posit ion, t hey’d only say: st r engt h and you can do it , you can do it , and I did ( DCS 8) .
Suppor t fr om a com panion can influence t he
w om an’s per cept ion of t he deliv er y r egar dless of t he
ad op t ed p osit ion . Resu lt s f r om a clin ical t r ial sh ow
t h at w om en w h o ar e su p p or t ed b y a com p an ion of
t heir choice dur ing labor get m or e sat isfied w it h t he
m edical care and orient at ion received, w hich indicat es
posit ive change in t he w ay healt h professionals deliver
car e( 15).
CI 5 – Post par t u m r ecov er y is fast er in t h e v er t ical
p osit ion
I t seem s I r ecover ed fast er , because t hey didn’t cut anyt hing, t her e w as only an int er nal st it ch. I had alm ost t en st it ches in t he fir st ( hor izont al deliver y) , alm ost t en st it ches in t he second and t hir d and in t his one ( ver t ical deliver y) I did not have a single one. And it seem s it w as so fast I didn’t suffer so m uch ( CSD 5) .
The w om en obser v ed t he differ ence bet w een
p ost p ar t u m w i t h ( h or i zon t al d el i v er y ) an d w i t h ou t
perineal sut ure ( vert ical delivery) , associat ing int egral
per ineum ar e higher am ong w om en w ho adopt
non-supine posit ions ( sit t ing, k neeling, squat t ing) dur ing
deliver y t han t hose w ho adopt t he supine posit ion( 11).
La t e r a l o r v e r t i ca l p o si t i o n s a r e a sso ci a t e d t o a
r ed u ced n u m b er o f ep i si o t o m i es( 6 ). Th u s, v er t i ca l
p osit ion d u r in g d eliv er y is on e of t h e st r at eg ies t o
r ed u ce p er in eal t r au m a, sw ellin g of t h e v u lv a an d
episiot om y( 11, 6).
N e g a t i v e a s p e c t s o f t h e v e r t i c a l a n d h o r i z o n t a l
posit ion s du r in g deliv er y
The negat ive aspect s of t he hor izont al posit ion
w er e m or e in t en sely r ep or t ed b y p u er p er al w om en
w h en com p ar ed t o r ep or t s on t h e v er t ical p osit ion
( Table 2 ) .
Tab le 2 – Cen t r al id eas on t h e n eg at iv e asp ect s of
t he v er t ical and hor izont al posit ions dur ing deliv er y.
Flor ian ópolis, SC, 2 0 0 6 - 2 0 0 7
s t c e p s A e v i t a g e N -s a e d I l a r t n e C n o i t i s o P l a c i t r e
V Horizontalposition
o t d e t a i c o s s a n o it c a f s it a s s i D -1 I C n o it i s o p l a c it r e v n i t r o f m o c s i d , r e g n o l s e k a t r o b a l l a t n o z i r o H -3 I C d n a n i a p , g n i r e f f u s s e s a e r c n i s s e n d e r it l a c i r t e t s b o f o k c a l e h T -2 I C r o b a l l a c it r e v g n i r u d n o it n e v r e t n i g n i e b t o n f o g n il e e f e h t s e t a r e n e g " d e p l e h " s e k a m n o it i s o p l a t n o z i r o H -4 I C h t i w n a m o w e h t f o t c a t n o c e h t e r o m r o b a l e h t s m r o f r e p m o h w tl u c if f i d e v o m o t e l b a g n i e b t o N -5 I C e l b a t r o f m o c n u s i n i a p g n i r u d t r e x e o t tl u c if f i d e r o m s i tI -6 I C n r o b e b o t y b a b e h t r o f h t g n e r t s
D i s c o m f o r t a n d l a c k o f o b s t e t r i c a l
in t er v en t ion s, r ep or t ed as n eg at iv e asp ect s of t h e
v er t ical posit ion ( CI 1 and 2, Table 2) , w er e r epor t ed
as posit iv e aspect s of t h e h or izon t al deliv er y ( CI 8
and 9, Table 1) . This fact show s t he veracit y of w hat
p u er p er al w o m en r ep o r t ed f r o m t h ei r ex p er i en ce.
They w er e em phat ic and sy st em at ically ar gued w hat
w as per ceiv ed as posit iv e in on e posit ion an d w h at
was negat ive in t he ot her. We consider it was due t he
ch ar act er i st i cs of t h e w om en w h o w er e ch osen t o
par t icipat e in t h e st u dy, t h at is, t h ey gav e bir t h in
bot h posit ions, w hich allow ed t hem t o com par e t heir
ex p er i en ces. Th e sa m e co m p a r i so n o ccu r r ed w i t h
negat ive aspect s of t he hor izont al posit ion ( CI 3, 4, 5
an d 6 , Tab l e 2 ) si n ce t h ey co r r esp o n d t o asp ect s
appoint ed as posit ive of t he ver t ical posit ion and w er e
inv er sely ex per ienced in t his posit ion.
I C 1 – D i ssat i sf act i o n asso ci at ed t o d i sco m f o r t i n
v er t ical posit ion
I felt dissat isfied in t he squat t ing posit ion, I felt r eally uncom for t able. I guess it can be bet t er , but y ou hav e t o be t r ained dur ing pr egnancy [ …] Then it can be bet t er , because [ …] you have t o know w hat t o expect . I got like, m y leg got num b because I didn’t know how t o get in a good posit ion ( CSD 1) .
Th e f a c t o r s t h a t i n f l u e n c e d t h e p o s i t i o n
adopt ed by w om en dur ing labor ar e innum er ous and
com plex an d it is dif f icu lt t o iden t if y t h e in st in ct iv e
conduct w om en w ould adopt because t his is st r ongly
i n f l u en ced b y cu l t u r al st an d ar d s r eco m m en d ed b y
car e p er m eat ed b y m ed ical p r oced u r es( 6 ). Per h ap s
m o d er n w est er n w o m en d o n o t h av e t h e m u scl es
r eq u i r ed t o st ay i n o t h er p o si t i o n s l i k e sq u at t i n g ,
k neeling or in k nee- chest posit ion for long per iods( 4).
Th e sq u a t t i n g p o si t i o n su p p o r t ed b y a st o o l o r a
cushion can be at t r act ive t o w om en dur ing deliver y( 6).
I t is im por t ant t o highlight t hat t he squat t ing posit ion
is not alw ays addr essed in educat ive act ivit ies dur ing
pr enat al car e. Mor eover, not all of t hem par t icipat ed
in t his pract ice as obser v ed in t his st udy.
Th e r ed u ct i o n o f o b st et r i cal i n t er v en t i o n s,
especially episiot om y, associat ed t o a m or e passiv e
p ost u r e of t h e p r of ession al w h o at t en d s t h e lab or,
gener at es t he feeling of not being “ helped” in t hese
w om en ( CI 2 ) . This per cept ion m ight be due t o t he
in t er v en t ion ist p r act ice in w h ich t h e p r of ession al is
t h e p r ot ag on ist an d w om en p lay a p assiv e r ole, a
p r act ice t h at h as b ecom e cu lt u r ally accep t ed . Th is
finding is support ed by r esear ch in w hich none of t he
w om en int er view ed expect ed nat ur al childbir t h w it hout
in t er v en t ion . Th e au t h or st r esses t h at w om en k n ow
t r ad i t i o n al h o sp i t al r o u t i n es d u e t o t h ei r p r ev i o u s
childbir t h exper ience and t hat t hey alr eady know w hat
t o ex pect fr om car e and do not k now alt er nat iv es t o
t he car e offer ed by t he biom edical m odel( 16).
CI 4 – Hor izont al posit ion m akes it difficult for w om en
t o com m un icat e w it h t he pr ofession al w h o per for m s
t h e deliv er y
[ ] ....when you’re lying down you see virt ually not hing... you r aise your legs and t hat ’s a bar r ier bet w een you and t he physician...you know ...in t he squat t ing posit ion you’r e on t op and see ever yt hing and I didn’t even get em bar r assed ( CSD 4) .
I n co n t e m p o r a n e o u s p r a ct i ce , t h e su p i n e
p o s i t i o n h a s a l w a y s b e e n a s s o c i a t e d t o t h e
car e of t he w om an in labor and dur ing childbir t h, and
i s a p o si t i o n r e co m m e n d e d i n t e x t b o o k s o n t h e
m e c h a n i s m o f l a b o r( 6 ). Th i s p o s i t i o n e a s e s t h e
professional “ w ork” w hen ( s) he has an int ervent ionist
view. On t he cont rar y, it m akes it difficult for w om en
t o act ively part icipat e in t he process because it inhibit s
t heir pr ot agonist r ole. The hor izont al posit ion per se
“ for ces” t h e par t u r ien t t o be k ept dow n , gen er at in g
an asy m m et r ic r elat ion bet w een t h e par t u r ien t an d
t h e p r o f e s s i o n a l . Th u s , i t c o n t r i b u t e s t o t h e
p r of ession al’s at t it u d e of ex er cisin g “ con t r ol”, w h ile
labor ing in t he ver t ical posit ion cr eat es t he feeling of
“ ex er cisin g con t r ol”. Th e aw ar en ess of pr of ession als
t hat w om en ar e t he m ain pr ot agonist s of t he pr ocess
is t he best w ay t o abolish t his at t it ude, so t hat w om en’s
d i g n i t y, i n d i v i d u a l i t y a n d v a l u e s a r e t a k e n i n t o
con sider at ion( 6 ).
CI 3 – H o r i z o n t a l l a b o r t a k e s l o n g e r, i n c r e a s e s
suffer ing, pain and t ir edness
There is no advant age in t he horizont al delivery because we suffer m uch m ore, [ ...] we have m uch pain. Aft er experiencing t he squat t ing, w e feel m uch bet t er . When I w as lying dow n, m y ow n body asked m e t o w ake up and sit [ …] had t o exer t m or e st r engt h, cont r act ions w ould t ake longer t o com e, so, you know , your leg is up t here, and t hen it t ook longer. I n t he horizont al, you had no opt ion t o sit or anyt hing like t hat ( CSD 3) .
The puer per al w om en explain in t he CSD how
t h e h o r i zo n t a l p o si t i o n i s u n co m f o r t a b l e , h i n d e r s
m o v e m e n t s , i n c r e a s e s s u f f e r i n g , t i r e d n e s s a n d
dur at ion of t he expulsive per iod, gener at ing a negat ive
percept ion. Qualit at ive st udies present sim ilar result s,
t h at is, w om en ex per ien ce m or e sev er e pain du r in g
t he supine posit ion and pr efer ot her posit ions( 17- 18).
CONCLUSI ONS
I n t h is st u dy, posit ive an d n egat iv e aspect s
appoint ed by w om en r egar ding ver t ical and hor izont al
p osit ion s ar e a r esu lt of t h eir com p ar ison b et w een
b ot h p osit ion s, sin ce t h ey h ad alr ead y ex p er ien ced
childbir t h in bot h.
Th e posit iv e aspect s of t h e v er t ical posit ion
r eflect t he need for w om en t o act iv ely par t icipat e in
t h e d el i v er y, t h e p er cep t i o n t h at t h i s i s t h e m o st
com f or t able posit ion an d eases f et u s ex pu lsion . On
t h e co n t r ar y, t h e h o r i zo n t al p o si t i o n m ak es t h ese
asp ect s d if f icu lt , g en er at in g a n eg at iv e p er cep t ion ,
si n ce i t h i n d e r s m o v e m e n t , i n cr e a se s su f f e r i n g ,
t ir ed n ess an d d u r at ion of t h e ex p u lsiv e p er iod an d
obst et r ical in t er v en t ion s.
Ge n e r a l l y, t h e p o s i t i v e a s p e c t s o f t h e
hor izont al labor ar e associat ed t o episiot om y, t o t he
oppor t unit y t o r em ain ly ing dow n and t he feeling of
b ein g “ h elp ed ”. Th u s, som e w om en r elat e t h e car e
deliv er ed dur ing childbir t h w it h t he need for a m or e
act iv e con d u ct of h ealt h p r of ession als an d a m or e
p assi v e on e f r om w om en ; t h ey ev en p er cei v e t h e
r educt ion of int er vent ions as a negat ive aspect of t he
v er t ical posit ion .
Consider ing all t he nuances appoint ed in t he
w om en’s discour se, t he posit ive aspect s of t he ver t ical
posit ion em er ged m or e int ensively and fr equent ly t han
t he negat ive ones. The CSDs appoint t hat t he posit ive
aspect s of t he v er t ical posit ion and negat iv e aspect s
o f t h e h o r i zo n t a l p o si t i o n a r e i n a g r e e m e n t w i t h
scien t if ic ev id en ce, g en er at ed in clin ical t r ials an d
sy st em at ic r ev iew s on t h e t h em e. Th is f act r ev eals
t hat w om en also per ceive t he adopt ion of t he ver t ical
posit ion dur ing obst et r ical pr act ice as beneficial.
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