ARTÍCULO ORIGINAL / ORIGINAL ARTICLE / ARTIGO ORIGINAL

DOI: 10.17533/udea.iee.v33n2a19

Episiotomy: perceptions from adolescent puerperae

Percepciones de las puérperas adolescentes sobre la episiotomía

Episiotomia: percepções de puérperas adolescentes

Graziele Figueiredo¹; Márcia Barbieri²; Maria Cristina Gabrielloni³; Elizete Sampaio Araújo⁴; Angelita José Henrique⁵

¹RN, Specialist. Unidade de Saúde da Família Vila São Pedro, São Bernardo do Campo-SP, Brazil. email: grazifig@hotmail.com.

²RN, Ph.D. Professor, Universidade Federal de São Paulo -UNEFESP-, São Paulo-SP, Brazil. email: mbarbieri@unifesp.brmbarbieri@unifesp.br.

³RN, Ph.D. Professor, Universidade Federal de São Paulo -UNEFESP-, São Paulo-SP, Brazil. email: crisgabrielloni@gmail.com.

⁴RN, MSc. Professor, Centro Universitário São Camilo e da Universidade Paulista, São Paulo-SP, Brazil. email: elizete.sampaio@uol.com.br.

⁵RN, Ph.D. Student. Professor, Centro Universitário São Camilo, São Paulo-SP, Brazil. email: angel.henrique@terra.com.br.

Receipt date: August 28, 2014. Approval date: April 15, 2015.

Article linked to research: Percepção de puérperas adolescentes relacionada à prática da episiotomia.

Subventions: none.

Conflicts of interest: none.

How to cite this article: Figueiredo G, Barbieri M, Gabrielloni MC, Araújo ES, Henrique AJ. Episiotomy: perceptions from adolescent puerperae. Invest Educ Enferm. 2015; 33(2): 365-373.

DOI: 10.17533/udea.iee.v33n2a19

ABSTRACT

Objective. To identify the perception of the teenager puerperas regarding the practice of episiotomy. Methodology. This is a study with qualitative nature developed with 11 teenage puerperas in the Obstetrics Unit of one hospital located in the metropolitan region of São Paulo, Brazil. Results. Teens knew of the existence of episiotomy, but they unaware the reasons for its realization. Pain, discomfort and burning were negative repercussions presented, but most of them believe that assisted procedure in their delivery showing confidence in the professional who carried it out. Conclusion. Adolescents have different perceptions on the practice of the episiotomy, ranging from resignation to outrage.

Key words: episiotomy; pregnancy in adolescence; humanizing delivery; obstetrical nursing.

RESUMEN

Objetivo. Identificar la percepción de puérperas adolescentes con relación a la práctica de la episiotomía. Metodología. Estudio cualitativo en el que se hicieron entrevistas semiestructuradas a 11 puérperas adolescentes en la Unidad de Obstetricia de un hospital localizado en la región metropolitana de São Paulo, Brasil. Los datos fueron sometidos a la técnica de análisis de contenido. Resultados. Las adolescentes sabían de la existencia de la episiotomía pero desconocían los motivos para su realización. Aunque el dolor, la incomodidad y el ardor representaron repercusiones negativas, manifestaron que el procedimiento ayudó al nacimiento y que tuvieron confianza en el profesional que lo llevó a cabo. Conclusión. Los adolescentes tenían diferentes percepciones sobre la práctica de la episiotomía, que van desde la resignación a las repercusiones físicas a las de indignación.

Palabras clave: episiotomía; embarazo en adolescencia; parto humanizado; enfermería obstétrica.

RESUMO

Objetivo. Identificar a percepção de puérperas adolescentes com relação à prática da episiotomia. Metodologia. Estudo de natureza qualitativa desenvolvido com 11 puérperas adolescentes em Unidade de Obstetrícia de hospital localizado na região metropolitana de São Paulo, Brasil. Resultados. As adolescentes sabia da existência da episiotomia, porém desconhecia os motivos de sua realização. Dor, incômodo e ardência foram as repercussões negativas apresentadas, porém grande parte acredita que o procedimento auxiliou em seu parto demonstrando confiança no profissional que o realizou. Conclusão. As adolescentes apresentaram percepções diversas diante da prática da episiotomia, variando do conformismo à indignação.

Palavras chave: episiotomia; gravidez na adolescência; parto humanizado; enfermagem obstétrica.

INTRODUCTION

Humanized practice in Obstetric care is complex, because it is related to technical-professional care, respect for individual rights, subjectivity and culture involved in the parturition process. Routinely perform episiotomy is a much questioned procedure in today's healthcare practice among professionals concerned with the humanization of the care parturition process. The episiotomy is defined as the injury resulting from surgical enlargement of the vaginal opening by making an incision in the perineum in normal delivery assistance.¹ Against the recommendations of the World Health Organization (WHO) that episiotomy is a procedure that should be avoided,² this intervention is still practiced routinely, especially in primiparous and parturients undergoing the procedure previously due to the lack of protocols of establishment or sole criteria, the interventionist care model widespread in university schools and disputes among authors, government agencies, health care institutions beyond the experience of each professional.³

The Ministry of Health does not provide an ideal percentage of practice of incision, but it is believed that this should be between 10 to 30% of the nearly 1.4 million vaginal births each year in Brazil.^4.5 In the other hand, WHO recommends performing selectively in about 10 to 15% of births.² A study performed in a public hospital in the Federal District with 384 women undergoing normal delivery in order to determine the prevalence and factors associated with episiotomy identified higher occurrence of incision in adolescents reaching 75%, even in the absence of evidence to support the association between maternal age and perineal trauma.³

The authors of a retrospective study in the Lisbon region that sought to compare the delivery and tracking of pregnancy in teenagers and adults maintain that the higher prevalence of episiotomy among adolescents is related to perineal muscles tense in this population prolonging the expulsive period and other factors as biological immaturity and the intent of professionals to protect the perineum of young mothers.⁶ Allied to this, during pregnancy and the parturition process, the woman, particularly teenager, often takes submission position due, many times, to the ignorance. In addition, the episiotomy like any surgical procedure in a healthy woman, should occur only after the information and the consent of the woman in labor, which does not happen in practice.⁷

In this context, the obstetric nurse professional takes a fundamental role, recognized by the Ministry of Health through Regulation No. 163 of September 22, 1998, to act in assistance to normal childbirth without dystocia in a committed way toward more humanity and best quality. Theirs actions should go beyond the intervention risks and pathologies, acting as a conduit of information relating to health and women's rights, favoring a more egalitarian relationship. However, prejudice and the lack of recognition from the doctors on the obstetric nurse's skills are barriers to their action. As a result, the nurse, characterized in being less interventionist compared to the doctors, is performing episiotomy in similar proportions to the other professionals.^1,3,8

A study conducted between 1983 and 2012 in order to characterize the scientific production of a nursing magazine revealed that the practice of nursing, a category where one might find episiotomy was subject of study in only 6% of the articles.⁹ In this context, the motivation for this study took place from the perception that the existing literature approaches the episiotomy theme, most of the time, just like surgical procedure in their technical and scientific aspects, clinical and biological and little discusses the vision of pregnant women. Thus, its relevance is based on the fact that you can provide a discussion and enable a reflection to the obstetric nurse about their practice, often ruled in paradigms that are difficult to be broken and reflected in rates far from acceptable.

Therefore, the approach of the proposed topic is of great relevance for nursing, as it enables the rescue of a fundamental discussion to the essence of the occupation: the humanization. Study the perception of adolescent mothers facing the practice of episiotomy is to study the feeling of young mothers who experienced a moment when the nurse is directly involved, the normal delivery. Facing exposure about the risks arising from the practice of incision and considering the changes in adolescent emotional scope self-esteem and reorientation of body image, even more intense in the adolescent mother, this study aims to identify the perceptions of adolescent mothers regarding the practice of episiotomy.

METHODOLOGY

This is a descriptive and exploratory qualitative study, carried out from May to July 2012 with adolescent puerperas admitted in the obstetrical clinic of a general hospital located in the municipality of Carapicuíba, metropolitan region of São Paulo, Brazil. The institution is intended for service users of the Unified Health System (UHS) and the unit that provided the backdrop for the study has 34 beds distributed between mother-child binomials and pregnant women with obstetric risk. In accordance with Resolution No. 466 of December 12, 2012 the National Council of Brazilian Health, referring to studies conducted with human beings, the project was submitted to the Research Ethics Committee of the São Camilo University Center and the data collection was initiated after the approval of this under the protocol 153/011 having been met, thus, national and international standards of research ethics.

The study proposal was presented personally by the researcher to adolescents, who agreed to participate, being oriented to voluntarily sign the Informed Consent. The sample for the study consisted of 11 adolescents admitted in the hospital postpartum unit, after consulting the medical records for screening those who met the inclusion criteria, namely: postpartum women between 10 and 19 years, oriented as to time and space, have been subjected to normal delivery with episiotomy and have already performed activities like waking up, sitting and walking after delivery. Excluded those who had genitourinary diseases. There was no refusal or withdrawal by the participants.

Once the young woman attended the inclusion criteria, she was informed about the study objectives, making clear the right to free choice of her participation, the ability to quit at any time, was informed of the non-participation of the researcher in the care team, causing no risk of damage to your service, and the secrecy guarantee on disseminating the results by replacing the real names for names of flowers. To obtain the data we used semi-structured questionnaire and verification of obstetric medical records. The interviews took place in a scenario that provided privacy, were recorded and later transcribed, lasted an average of ten minutes.

Qualitative data were analyzed through content analysis proposed by Minayo, which has three stages: pre-analysis, material exploration and treatment of results and interpretation.¹⁰ Thus, in a first moment a reading was performed to have a vision of the whole, allowing the choice of material to be analyzed, and was later made the approach of similarities and identification of differences in order to build relevant descriptive categories for achieving the study objectives by specifying the central ideas. Excerpts of the narratives were used to illustrate the content of the categories.

RESULTS

Characteristics of the sample. The average age of the 11 participants was 17.8 years, ranging from 15 to 19 years. Most adolescents declared no work outside the home (7), two had paid job and two were students. The highest level of education was observed in two young women who reported having completed high school. Five reported to have not completed secondary education and four discontinued their studies before completing elementary school (3). With regard to marital status there were those who reported maintain consensual union with the partner (7), some said they are single (3) and only one officialized the union. Those that mentioned maintain consensual union or being married refer living with partner and son(s), one of which declared also live with her mother. The other claimed to live with other family members without the partner's presence.

Previous knowledge of episiotomy. Most adolescents had already heard about episiotomy and the possibility to be made during delivery, as can be seen in the following statements: I had heard! My mother and my sisters had already spoken (Begonia); About this, yes! People who had babies, colleagues (Jasmine); I had heard because at the first delivery they did (Amaryllis). The way in which they expressed demonstrates that did not have a deep knowledge of the subject. Regarding the source of information, draws attention the fact that none of them have indicated the health professional. Although those who have demonstrated knowledge of episiotomy was the majority, none of them could inform the reason of performing the incision. When asked if they knew the reason for the procedure the answers were: [...] I did not understand, the nurse who now came up and told (Fleur de Lis); Not (know why) (Gardenia). While some had knowledge, however limited, others not even have heard of: I had never heard that cut down there. (Calla Lilies); I had never heard (Fleur de Lis).

Information/authorization for the episiotomy. Other aspect discussed during the interview was regarding the authorization request after informing about episiotomy. Some mothers reported that they were informed, but that the authorization for the procedure was not requested: Warned [...]. They did not ask the permission (Azalea); [...] They warned! (Begonia). Other puerperae interviewed were not even informed about the procedure, as demonstrated in the following words: No! Just did! I did not know it was going need to cut (Calla Lilies); Did not warn me [...] (Violet). Some puerperae reported that they learned of the cutting only upon episiorrhaphy: I wasn't informed! I learned at the time they began stitching me (Gardenia); They communicated about the points, but not the cut (Daisy). Stands out among the interviewees, the speech of a puerperal woman, which was not informed at any time about episiotomy and was aware of the procedure a few hours after birth when was already in the room, at the maternity, being questioned by the professionals on the appearance of the cut: No! They just did it, now that I know why women (nurses) asked me but did not warn (Fleur de Lis). Another aspect to note is the fact that the doubt about the authorization request, showing also the time of delivery is not the best for the woman to be informed of the incision, it is vulnerable due to pain and discomfort lacking condition to judge the risks and benefits of a procedure: No! If they asked I accepted right away (laughs) (Tulip).

Physical repercussions of episiotomy. Some of the interviewees pointed as effects of episiotomy the hassle, pain and burning, as shown in the following words: In the beginning it was bad. (Now) is sore! (Rose); It bothers when the leg moves (Daisy); Pain in urinating and sitting depending on the position (Calla Lilies); A little pain in the stitches (Tulip); Is burning when moving (Azalea); It hurts a little, just when I cough(Gardenia). Other reported no discomfort related to the procedure: So far it does not hurt! (Amaryllis); It is normal (Fleur de Lis).

Perceptions related to professional and procedure. There were puerperae who reported believing that episiotomy came as a method of shortening the delivery, relieve pain and characterized the assistance provided as appropriate: I guess they did it well because I was feeling a lot of pain, so it helped (Azalea); It helped a lot, but it would have taken more time [...]. I thought everything appropriate, I was given much attention (Begonia). In contrast, other puerperae demonstrated discontentment when asked about their perceptions related to the professional and procedure: (I would like) they had more care (Rose); Just this question of the cut, at the time no one told me anything (Fleur de Lis). One of them did not even have an opinion on their perception of episiotomy and their speech demonstrates certain compliance with the situation: Nothing! What should I do? (Gardenia). Other expressed confidence in the professional judgment about the necessity or not of the episiotomy: I trust the professionals! It is required! (Jasmine); I trust the doctors! (Tulip).

DISCUSSION

The National Demographic and Health of Children and Women (PNDS) 2006 reveals that in Brazil there is a reduction in the age at which women have their first child compared to previous decades, increasing the number of women who become pregnant between 15 and 19 years.¹¹ a study conducted in order to investigate the effects of cryotherapy in relieving pain in 1338 puerperal women undergoing episiotomy in the Airport Complex Maternity in Ribeirão Preto showed that 32% of women exercised some kind of paid occupational activity. All other have declared themselves as domestic workers (68%). ¹² Similar scenario was observed in the present study, with the addition of a portion of students, which is supposed not to have been observed in other studies due to the higher age group. In this context, according to the PNDS-2006, 41.8% of women between 15 and 19 years have never worked and 28% are currently working, and 11% had never worked by the existence of children and the need to provide maternal care and 9% because they have become pregnant.¹¹

The level of education is related to the age of onset of sexual activity. Data from the United Nations Educational, Scientific and Cultural Organization (UNESCO) show that adolescents are sexually active at an earlier age, since the first sexual intercourse that was taken in the 90s to 16 years of age, in the last decade fell to 15 years on average.¹³ PNDS data show that there is a tendency of increase in early sexual activity of age according to the increase in the level of education.¹¹ Also the low level of education is related to a higher incidence of episiotomy. A quantitative study of 279 medical records of puerperal women, aiming to describe the profile of women who had their children vaginally and its relation to the frequency of perineal injury, showed that 50.18% of women had lower education. According to the authors, this fact complicates the understanding of birth physiology, limits the knowledge about their bodies, about the changes caused by pregnancy and about their rights, being at the mercy of the decision of professionals.¹⁴

Regarding the obstetric history, the present study found a higher incidence of first pregnancy. Similarly, a study performed on a referral center in the state of Pernambuco in order to analyze the prevalence and factors associated with episiotomy in 495 women undergoing vaginal delivery showed that primiparous and women with no previous vaginal delivery presented ten times greater risk of being subjected to the procedure than pregnant women in general.¹⁵ It was not objective of this study to evaluate the the episiotomy rate in pregnant adolescents in a university hospital, although, in a similar study, which the objective was to evaluate the prevalence and the intensity of pain in 303 puerperal women in Collective Accommodation Unit of a University Hospital in the city of São Paulo, was found the episiotomy rate of over 70%, with relation between the fact and the practical teaching at the institution.¹⁶ Thus, it is believed that the episiotomy rates higher than those recommended by the Ministry of Health and WHO can be found at the mentioned institution, however it is recommended that quantitative studies should be conducted.

With regard to prior knowledge about episiotomy, literature findings corroborate the data found in the current study. A study in a teaching hospital in Minas Gerais in order to assess the knowledge and the participation of 16 puerperal women who had undergone the episiotomy in their delivery process, it was observed that 31.2% of them had no knowledge about the procedure, do not know what it was nor its purpose, although it is a routine practice at the mentioned institution. ¹⁷ Similar to this study, a qualitative study with 14 women held in a Basic Health Unit in the city of Teresina, Piauí, Brazil found examples of women who had not had any information about the episiotomy before delivery.¹⁸ Another study, conducted in a public maternity the interior of Bahia in order to assess the knowledge and the participation of 20 puerperal women in episiotomy verified, similar to the current study, those who had some knowledge, presented as source women in their families or previous experience. It is noteworthy the fact that the health professional does not appear as a source of information in the literature, either in the current study, hiding from their duty to inform and enlighten the woman throughout the pregnancy and childbirth on the procedures to which the your body can be subjected.¹⁹

As long as in the present study it was unanimous the lack of knowledge of the real reasons for episiotomy, similar studies showed the abbreviation of the expulsive period, passage optimization to the fetus, prevention of lacerations and of the risks to the baby as verbalized by the answers of the volunteers^{. 17,19} Ordinance No. 1820 of August 13, 2009, which provides for the rights and duties of health users states that must be guaranteed clear, objective, respectful and understandable information on objectives, risks and benefits of diagnostic, surgical, preventive or therapeutic procedures. After such information, should also be ensured free, informed and voluntary consent of any procedure and that may be revoked at any time without loss of any kind. ²⁰

Despite their rights, this research pointed out that some mothers only had the communication of episiotomy at the time of its completion, others during the suturing and others still haven't at any time of the delivery care. Furthermore, the authorization for the procedure was not requested for any of them. In literature it can be observed studies with similar results, showing that most women did not receive any information about the procedure. Those who said they had been informed, in fact were only reported during the expulsive period or already after delivery and still showed doubts if they were actually reported.^17,18 The episiotomy without prior notification of the woman is one of the great examples of disrespect for their rights.¹⁷ In this context, the ignorance of women contributes to their right to be informed in advance and consent the realization of obstetric interventions is not observed.¹⁸

However, the professionals, especially medical residents and preceptors, believe that this decision should be taken only by the professional as they consider that at this time the woman is unable to decide on what is best for herself and her son. Thus, some authors point out the violation of one of the basic rights of women and one of the principles of bioethics, autonomy.^{17, 21} One of the statements that deserves mention is the one of a teenager after many hours of labor was unaware of the completion of the episiotomy. This fact allows the assumption that the woman when is unaware of the procedure, also has not been oriented in relation to wound care and absorbing the stitches. It was highlighted among the the interviewees the statement of one of the puerperal women who made it clear that his greatest desire during the expulsive would be the relief of your pain and that would have accepted any procedure for that purpose. In this context, the authors claim that during childbirth, the pain arising from the process and the expectation for it to finish as quickly as possible, makes the woman accept episiotomy without questioning it. ²² The Ministry of Health recommends that during labor the woman does not receive excessive information and it is not required to take decisions on matters for which it would need more tranquility and time for consideration. ⁴

Thus, the perfect time on addressing the subject about episiotomy is prenatal care when the trader has the opportunity to inform, guide the risks and benefits, the reasons for the procedure, as well as to prepare the woman for the possibility of being submitted to the incision. Similar to the speech of a teenager puerperal who had no opinion on the procedure and showed certain compliance with the situation, the literature points out that, although the majority of adolescents included in the study have had a considerable number of prenatal consultations, many times the young women do not express any opinion on the episiotomy because they are not even informed about the procedure.²³ Such situation was also demonstrated in this study, in which some adolescents have shown discontentment with the procedure and with the attitude of the professional, but not questioned.

Regarding the physical repercussions of episiotomy, there were reports of pain, burning and discomfort, consistent complaints with those found in studies aimed to evaluate pain.^1.12 Our findings are in agreement with the literature with regard to the fact that some women do not express any different nuisance related to episiotomy, associating previous experiences, anesthesia and the birth itself.²² However, the denial of pain and discomfort is discussed in the literature, in a study in which 76% of women said well bear the pain. The author ensures that often this statement is a woman's way to keep the image of "good mother". ¹²

The pain in the postpartum period, despite being the main complaint and the most frequent morbidity resulting from the delivery process, is undervalued by professionals and even by the woman and their families because of the attention directed to the newborn.^1,12 Corroborating the findings of the current study, the subordination of women in relation to the trader decision, especially the doctor on the episiotomy is something documented in other studies. Authors report that the woman even not receiving appropriate clarification and not being consulted during the decision to hold or not the procedure takes as normal and necessary medical decisions.¹⁹ In this context, professionals often leave no room for the expression of the will of the woman and that it may exert her rights by, also believing in the superiority of their knowledge, making the scientific and technological issue as more important than the quality and welfare the binomial. ²⁴

A decisão final sobre a realização da incisão deve ser do profissional que assiste o parto uma vez que se presume que este possui qualificação adequada para indicar procedimentos e evitar complicações, porém é preciso que tal decisão seja tomada a partir de evidências científicas e que práticas realizadas por rotina sejam abandonadas, bem como que o direito da mulher de ser informada e consentir a realização das intervenções necessárias seja considerado.²¹ É neste contexto de orientação, humanização, respeito aos direitos da mulher e restrição do uso da episiotomia que o enfermeiro deve estar inserido.

The final decision on the realization of the incision should be of the professional who assists the delivery since it is assumed that it has adequate qualification to indicate procedures and avoid complications, but it is necessary that such a decision is taken based on scientific evidence and that activities undertaken routinely be abandoned and that the right of women to be informed and consent to carry out the necessary interventions to be considered.²¹ It is In this context of orientation, humanization, respect for women's rights and restriction of the use of episiotomy that nurses should be inserted.

Conclusion. It is concluded that adolescent girls have a limited knowledge of the episiotomy, unaware of the reasons for its implementation, present the pain as the main impact of the procedure and demonstrate different perceptions on the practice of incision, ranging from conformism to indignation by disregard of their right to choose. Nevertheless, it is common confidence in the knowledge of the professional.

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