Obstetric nursing: trajectory and constitution in seven decades of the UFRGS Nursing School

Enfermería obstétrica: trayectoria y constitución en siete décadas de la Escuela de Enfermería de UFRGS

ABSTRACT

Objective:

Describing the trajectory and constitution of Obstetric Nursing in seven decades of existence of the Nursing School of the Universidade Federal do Rio Grande do Sul (EENFUFRGS).

Methods:

Theoretical and reflexive study based on documents and author experience. Data analysis was based on Michael Foucault’s theoretical framework.

Results:

Analysis identified knowledge and forces that structured and characterized the Arena I: the creation of EENFUFRGS; the Arena II: Obstetric Nursing in graduation; the Arena III: Obstetric Nurses formation, and Arena IV: we are not alone!, highlight the importance of EENFUFRGS in its relationship with other entities.

Final considerations:

During the 70 years of EENFUFRGS existence, it maintains the vitality of a solid institution in its principles coupled with a youthful in disposition, facing necessary challenges to guarantee quality teaching and practice of Obstetric Nursing.

Keywords:
Obstetric nursing; History of nursing; Education

RESUMEN

Objetivo:

Describir la trayectoria y constitución de la enfermería obstétrica en las siete décadas de la Escuela de Enfermería de la Universidade Federal de Rio Grande do Sul - EENFUFRGS.

Método:

Estudio teórico reflexivo documental basado en documentos y experiencias descritas por los autores. El análisis de los materiales fue basado en las teorías filosóficas de Michel Foucault.

Resultados:

Se identificó conocimientos y poderes que estructuraron y caracterizaron las Arena I: la creación de la EENFUFRGS; Arena II: Enfermería Obstétrica en la graduación; Arena III: formación de enfermeras obstétricas; y Arena IV: no estamos solos, que destaca la importancia de EENFUFRGS en sus relaciones con otras entidades.

Consideraciones finales:

En sus 70 años de existencia, la EENFUFRGS mantiene la vitalidad de una Institución sólida en sus principios pero joven en su disposición, enfrentando los desafíos necesarios para garantizar la enseñanza y el ejercicio de la enfermería obstétrica de calidad.

Palabras clave:
Enfermería obstétrica; Historia de la enfermería; Educación

RESUMO

Objetivo:

Descrever a trajetória e constituição da Enfermagem Obstétrica em sete décadas de existência da Escola de Enfermagem da Universidade Federal do Rio Grande do Sul - EENFUFRGS.

Método:

Estudo teórico reflexivo em base documental cujas fontes de consulta foram documentos e experiências descritas pelos autores. A análise dos materiais foi estruturada com base no referencial teórico filosófico de Michel Foucault.

Resultados:

Identificaram-se saberes e poderes que estruturaram e caracterizaram a Arena I: criação da EENFUFRGS; a Arena II: Enfermagem Obstétrica na graduação; a Arena III: formação de enfermeiras obstétricas e a Arena IV: não estamos sós, que salienta a importância da EENFUFRGS em suas relações com outras entidades.

Considerações finais:

Em 70 anos de existência a EENFUFRGS mantém a vitalidade de uma Instituição sólida em seus princípios e jovem na disposição, enfrentando necessários confrontos para garantir o ensino e o exercício da Enfermagem Obstétrica de qualidade.

Palavras-chave:
Enfermagem obstétrica; História da enfermagem; Ensino

INTRODUCTION

This article aims to describe the trajectory and the constitution of Obstetric Nursing throughout its seven decades of existence in the Nursing School at the Universidade Federal do Rio Grande do Sul - EENFUFRGS, by recovering the history of the formation of the midwives and obstetric nursing and, also, by creating new links and seeing the history of the practices carried out by Obstetric Nursing under new colors. Obstetric Nursing has never developed out of a fighting arena, and the EENFUFRGS had a major role in the battles fought through time, which, in some cases, were not well known. The term fighting arena, in this article, was meant to signify the knowledge and powers of Obstetric Nursing as inserted in power struggles whose productive effects are the results of their confrontation. Power, in this article, must be understood as the actions of one on another with another and therefore, it is an ethical and non-violent game whose struggle evidenced production, and not destruction; an action that got renewed with every battle unlike in wars or actual fights, whose effects would be domination or an end. Therefore, in the fighting arenas of Obstetric Nursing, there is a place for resistance, which, also, is a place for freedom, that is, a condition for the existence of power, since freedom is needed for said power to be exerted1. In these fights, the power, instead of being repressive, stimulates and creates conditions of freedom, for the knowledge of Obstetric Nursing to stand out.

METHODOLOGY

This was a reflective, theoretical, document-based study, whose sources were documents and experiences described by the authors. The analysis of the materials was structured based on the theoretical references of the philosopher Michel Foucault, such as power, knowledge, and freedom1, contingent on specific locations, or arenas2, where discourses of Obstetric Nursing were put into action.

RESULTS

Considering the materials analyzed, pieces of knowledge and aspects of power were found in nursing, according to which Arena I was characterized as the creation of the EENFUFRGS; Arena II with the emergence of Obstetric Nursing in graduation; Arena III with the formation of obstetric nursing; and Arena IV: We are not alone, which highlights the importance of the EENFUFRGS in its relations with other entities.

ARENA I: THE CREATION OF EENFUFRGS

The EENFUFRGS was created in December 4th, 1950 and was the first to offer nursing graduation courses in Rio Grande do Sul. It was created as an annex to the UFRGS Medicine School and remained as such until 1968. The candidates to the nursing course needed to have complete high school, present certificates of physical and mental health, moral reputability, and vaccinations, in addition to passing exams about chemistry, physics, and biology. They also had to be from 18 to 38 years of age. The course was full-time for both students and professors. They also had the option of living in a board-school like regime until the decade of 1960. The participants of the course were called "the dean's pupils". The conviviality made possible to monitor their behaviors and make them uniform, to exercise obedience, dedication, discipline, and abnegation3.

The classes were taught in rooms in the Medicine School, and the practical classes took place in the sisterhood Santa Casa de Misericórdia de Porto Alegre. Professors of the Medicine School taught classes about subjects such as physiology, human anatomy and obstetrics; classes on the clothing of pregnant women, hygiene and psychology of pregnancy were taught by nurses, sometimes obstetric nurses, who were professors at the EENFUFRGS4.

As the number of professor nurses grew at EENFUFRGS, the physicians stopped teaching classes in the professional level subjects. In this arena, one can think that the fight for the teaching of Obstetric Nursing is at peace in EENFUFRGS, since the subject related to this field is taught by professors who are obstetric nurses.

ARENA II: OBSTETRIC NURSING IN GRADUATION

The National Education Directives and Bases (law 4.024/1961)5 instituted new minimum syllabuses for education. Its specific rules for nursing were regulated by the Federal Council of Education under protocol No. 271 from 19626. Up to this point, nursing courses formed nurses in three years. There was a common core of subjects taught in the first two semesters and in the other four semesters, the students were sent to the specialties they chose. The protocol from 1962 maintained the specialties by keeping a three-year graduation, followed by qualifications among which the students could choose in the fourth year. The alumni of the UFRGS nursing course could finish those specializations after graduating, without undergoing any additional selective processes, since these qualifications were the continuation of the graduation course.

The reform of the syllabus in 1962 was consolidated in 1968, with the University Reform7 movement, which took place in a period of political turbulence and scientific development. In this period, subjects related to curative techniques were prioritized over preventive health ones, and learning in the hospital environment was considered more valuable8.

The syllabus of the graduation course in nursing at EENFUFRGS underwent other changes until 2013, when the length of the course increased from four years and a half and 4,035 hours to five years and 4,121 hours. The reorganization of the graduation course led to the inclusion and exclusion of subjects and contents. Currently, the subject that mainly discusses nursing obstetric care is in the fifth stage of the course and is called Nursing Healthcare to Women and Newborns. The Education Plan of this subject describes specific content related to gestation, childbirth, and puerperium, based on national programs and policies9, which are addressed in classroom and in practice settings. The mismatch between what is prescribed for the application of evidence-based practices and the actions of nurses in the assistance to child delivery has led students to raise questions to the professors. The recognition that which is taught brings better results and satisfaction to the population cared for has led to the insertion of students and professors in the movements for the humanization of delivery and birth. This, within the framework of references proposed, characterized a fighting arena where students and professors perceive the differences between the hegemonic model, which is mainly medical and hospital-focused, and the one prescribed by Obstetric Nursing healthcare to women, while they, simultaneously, seek to implement good practices. The fight between violent and hegemonic arguments and those based on scientific evidences and ethical attitudes about child labor and birth, take place through discourses that it accepts and makes function as true, a device1 which allows one to distinguish between true and false enunciates and which the EENFUFRGS, as the "statute of those who are charged with saying what functions as true"1, makes go around, among colleagues, students, and the community.

ARENA III: THE FORMATION OF OBSTETRIC NURSES

The National Education Law of Directives and Bases from 2005 enabled the formation of obstetric nurses in two different ways, both in higher education courses: through residency programs or through specialization courses. Both required the student to be graduated in nursing.

Courses to form obstetric nurses take place in EENFUFRGS since 1966. From 1999 on, in the midst of discussions on healthcare for labor and childbirth10, the Ministry of Health got involved in the changes of the healthcare model, as it sought to bring the practices used closer to the best-available scientific evidences, a movement which received the support of the Rede Cegonha (the “Stork Network”) in 2011. Among programs, strategies, resolutions and discussions, the country started going in the same direction of international agreements it subscribed, as to diminish mother and child death. From that moment on, agreements have been formed with universities and health secretariats in the entire national territory for the financing and promotion of specialization courses in Obstetric Nursing, especially within federal universities. That was done to form nurses that can work in public maternities while being associated to the Rede Cegonha9, since, in this program, the obstetric nurse is the professional who is indicated to aid women in regular-risk labor and childbirth.

In 2013, the Ministry of Health coordinated with the Universidade Federal de Minas Gerais to form 900 obstetric nurses in the country. In the first of the three editions predicted for the formation of these professionals, EENFUFRGS was one of the 18 federal higher education institutions which participated, each being from a different state. In 2016, EENFUFRGS was the only institution in the South and Southeast regions of the country to form 12 professionals, who originated from different regions of the Rio Grande do Sul state.

Between 2011 and 2014, the EENFUFRGS participated in the Coordinating Group of the Rede Cegonha of Rio Grande do Sul, created by the Bipartite Inter-managerial Commission/RS11, in which representatives of the related institutions got together to discuss the strategies for making Rede Cegonha viable in Rio Grande do Sul, where the Specialization Course in Obstetric Nursing was announced in 2014. In early 2015, the Regional Council of Medicine of Rio Grande do Sul edited Resolution 02/2015, which found dangerous the "possibility of having labor without the presence of an obstetrician, a pediatrician, a neonatologist, and even, without the presence of a physician"12. The resolution prescribed that it is "the duty of the physician of the Clinical Body [the hospital] to communicate these situations to the Clinical Direction and to the Ethical Commission, whenever they took place, and to the CREMERS"12, when a professional other than a physician provided healthcare to childbirth. The resolution aimed to make any professionals who were not physicians and aided in childbirths, that is, nurses, liable in civil and criminal courts. The political entities that represented nurses in Rio Grande do Sul, such as the Brazilian Association of Obstetricians and Obstetric Nurses, the National Nursing Council, and the Nurses’ Union, appealed against this resolution to the Ministry of Health, asking for its immediate suspension. They stated that, in addition to trying to create laws about another profession, it put the health of the population at risk. Months of intense negotiation took place until federal justice suspended the resolution with an injunction.

The effects of Resolution 02/2005 were devastating to the specialization course, since the hospitals of Rio Grande do Sul felt they could not offer their institution for the nurses to practice labor assistance. The specialization students had to be sent to the Bairro Novo Maternity, in the city of Curitiba - PR, to find a setting to practice childbirth assistance. The formation of this group of 12 nurses was delayed to May 2016. Rio Grande do Sul could not participate in the second edition of this program due to the interdictions to the assistance and to the teaching of Obstetric Nursing put in place by class entities and hospitals that do not have the power to legislate over nursing. It was only in May 2018 that another course for the formation of specialists could be started, when the Ministry of Health directly established an agreement with the EENFUFRGS. The 15 seats in this course were also filled with nurses from institutions linked to the Rede Cegonha, coming from different regions of Rio Grande do Sul.

From 1966 to 2019, EENFUFRGS formed 146 obstetric nurses in 11 courses, while fighting to open more spaces where these professionals could act and to improve the healthcare of the population.

ARENA IV: WE ARE NOT ALONE!

Brazilian obstetrics underwent a strong influence from obstetric practices from European countries which took part in the colonization of Brazil, such as Portugal, England, France, and the Netherlands. From the creation of medicine and childbirth courses in Brazil, obstetric practices started to be strongly influenced by the United States13.

With the support of the WHO, in the 1980, international groups of researchers coordinated to systematize studies on the efficacy and safety in the assistance to pregnancy, labor, and post-birth, since, with the worldwide adoption of the American technocratic model, costs with health increased, but the results in labor assistance did not improve, and there was no reduction of mother and perinatal mortality. The American influence expanded in the research financing plans, showing their economic and corporative power14.

Starting at the International Conference on Appropriate Technology for Birth, which took place in Brazil, in 1985, participating countries established specific policies about the adequate technologies for private and public health services, in addition to creating joint actions with their own communities to evaluate technologies of labor and childbirth healthcare. The Fortaleza charter, which resulted from this conference, was published in the journal Lancet, and the WHO was named as its author15. This led to the mobilization of researchers, who carried out a systematic review of nearly 40,000 studies on labor and childbirth published from 1950 on, including 275 practices of perinatal assistance which were classified according to their efficiency and safety16. These are the practices that inspire the teaching and research in the field of Obstetric Nursing and in which the expertise of these professionals is based, showing itself as an important fighting arena, in which thoughts, opinions, practices and care practices are exposed.

In 2000, with the persistence of challenges imposed to the world population, the UN established goals for the development of the millennium, to be reached until 2015, among which is a 75% diminution of mother mortality. However, Brazil did not reach this goal, and the death rates have started growing once again17. Among the strategies recommended to improve the health of the populations the WHO suggests the need to form, value, and give support to obstetric nurses, highlighting that these are essential to promote respectful and quality care to the mothers and newborns18. In 2018, the WHO published new recommendations, stating that the presence of obstetric nurses leads to positive experiences at childbirth19.

Brazilian governments have been intensifying the debate with regards to labor and childbirth. The Rio Grande do Sul State Secretariat published Resolution 206/17 from the SES/RS, which prescribes that nurses should be present "24 hours a day and the commitment to gradually insert obstetric nurses in the healthcare process"20. The Ministry of Health, in turn, released in 2017 the Program for the Improvement and Innovation of Healthcare and Teaching in Obstetrics and Neonatalogy - APICE ON(21). While the resolution prescribes the inclusion of nurses in a direct and continuous assistance for childbirth, the APICE ON proposes the qualification of personnel in teaching hospitals of the Single Health System network, where there is a great resistance to the changes. This qualification is suggested as an important possibility to diminish the excessive use of unnecessary interventions during labor and stimulating the inclusion of obstetric nurses in this type of care.

FINAL CONSIDERATIONS

The EENFUFRGS is a pioneer in the nursing graduation courses at Rio Grande do Sul. Since 1950, the institution follows and promotes changes in the healthcare practices and in public policies associated to the best scientific evidence for labor and childbirth attention. It also faces difficulties together with class entities to improve the formation and the recognition of the social importance of the obstetric nursing, together with the population.

It is in such a setting of fights that the EENFUFRGS has guaranteed the dignity of teaching and exercising practices related to Obstetric Nursing, recognizing the nurse as the professional who stands out with regards to labor and childbirth care. Despite the hardships, the institution has formed obstetric nurses that originate from different regions of the state, promoting a decentralization and a socialization of important knowledge for the dissemination of effective and innovative practices, based on the best scientific evidences. During its 70 years of existence, the EENFUFRGS maintains the vitality of a solid institution in its principles, while showing a young disposition to face any challenges necessary to guarantee the quality teaching and exercise of Obstetric Nursing in Rio Grande do Sul.

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Publication Dates

• Publication in this collection
  08 May 2020
• Date of issue
  2020

History

• Received
  25 Apr 2019
• Accepted
  12 Feb 2020