Obstetric Nursing : an Integrative Review

Evidence-based research, tend to encourage the development and/ or use of the results found, in the clinical practice. The amount and complexity of information in health, requires the production of literature review methods, such as integrative review, which provide a support in the form of synthesis. The aim of this study was to analyze the scientific literature available on midwifery in SciELO database from 2010 to 2015. It presents general concepts and stages of development of the integrative review, as well as relevant aspects of the applicability of this method for research in nursing and health in general. The integrative review is a research method that allows a systematic search, critical assessment and the promotion of a synthesis of the available evidence on the subject investigated. The publications reviewed here, have shown how it is relevant to clinical practice, the participation of nursing in all stages of the gestational cycle, including childbirth and the postpartum period. Also provided to identify gaps that that will direct the development of future research, such as those relating to liability issues of the nursing area hardly contemplated in studies of care in obstetrics. Obstetric Nursing: an Integrative Review REVIEW


Introduction
It is true that nurses are professionals who are constantly challenged in their profession, not only in emergency and emergency situations, but also in the search for new scientific knowledge that promotes an improvement in patient care.[1] Obstetric nursing involves skills and abilities that make it possible to provide care that is integral, respecting childbirth as a natural physiological process, which will have positive repercussions on maternal and child health [2].The training of such specialized professionals involves successful experiences, observed in other countries, where it is not always medical professionals who are the promoters of the primary care of healthy women when in childbirth [3].Therefore, it is noted that the obstetrical nurse's performance becomes strategic, with a fundamental role in health services, when assisting women in childbirth, contributing significantly to the improvement of maternal health and for the success of all process.
Evidence-Based Research (PBE) is a methodological technique for solving health decision-making problems, which incorporates the best professional strategies used in the context of care through evidence of scientific work4.It involves everything from the definition of the problem to the search for and selection of the available evidence, criticism of the authors and finally an evaluation of the results found.Therefore an approach that encourages health care, based on information built on scientific knowledge [5].
The work with scientific evidence requires some skills of the health professionals, since it requires an association of the results obtained from research, in their daily practice, to solve the associated problems found [6].The results of researches are the main tools of PBE [5].
For the implementation of the PBE, a literature review is necessary in order to select the material, classify and carry out a critical evaluation and a synthesis of the available evidence related to the subject investigated.Among these, we highlight the integrative review and the systematic review [7].
The systematic review of the literature is a research method that has been developed for evidence-based medicine.The Cochrane Foundation (with several collaborating centers in different countries) is the organization responsible for the elaboration of the method and its dissemination for the effectiveness of the interventions of those who work in the health area.
By definition, it would be the application of scientific strategies, limiting the biases in the selection of articles, which are critically evaluated, organized and synthesized the results of the most relevant studies, within a specific topic [8]: 133.Studies of this type have as general principle the exhaustion in the searches, through very explicit inclusion and exclusion criteria [9]: 143.
Another aspect of this method is that it aims at the exhaustion of studies in a given subject investigated [10].
On the other hand, the integrative review of the literature, as a research method also used in the PBE, aims to synthesize and organize the results of research on a given topic or issue, in a systematic and orderly way, in order to contribute to the deepening of discussions on the subject investigated.Since the 1980s, integrative literature review has been reported as an important research method [11].
Some time ago, more precisely since the 1990s, scientists around the world have made various efforts in implementing actions to promote development.Be it social, economic or human.Since in 2000, United Nations leaders established the socalled Millennium Declaration [12][13].
There has been a consensus that maternal and child mortality can only be addressed from the involvement of all, both professionals and families.Hence a greater need for actions for professional qualification in health, antenatal care, childbirth and puerperium [15][16][17][18].
It is on the basis of these prerogatives and in the recommendations of the World Health Organization (WHO) that the participation of the obstetrician nurse in childbirth situations has grown, as well as widely disseminated and stimulated care and nonintervention, as a reference throughout the country [19].
This non-dialogical view still tries to guarantee its hegemony in Brazil and in other countries, emphasizing the biomedical model as a unique reference in the approach to health and disease.It is a reductionist view that ignores the complexity of the interrelationships between biological, sociological, economic, environmental, and cultural factors that involve human suffering.The reasoning in the mechanistic paradigm of Newtonian physics, already overcome, but still impregnated in the medical mentality, has led the Official Medicine to exclude from its conceptions and practices, human dimensions, among them, religiosity.
The main objective was to analyze and synthesize the results of some articles dealing with obstetric nursing between 2010 and 2015, available in the SciELO database, in order to provide clarifications and reflections in the obstetric health and nursing scenario.More specifically, to analyze articles in the area of obstetric nursing, to elaborate an integrative review, highlighting the most relevant aspects as to its applicability.

Methods
This is an integrative literature review.A methodological strategy that aims at a synthesis of the knowledge produced on the selected theme, as well as the incorporation of the applicability of the results of the most significant studies [19][20].
This method is developed in six steps, namely: 1) the formulation of the problem, from a guiding question; 2) the search of the data through the literature, in order to compose the sample; 3) data collection; 4) a critical analysis of the included studies; 5) a discussion of the results and 6) the presentation of the integrative review in the form of a synthesis of the studies analyzed [19].
For the search in the SciELO -Scientific Electronic Library Online database, (SciELO) the guiding question was formulated, previously described: What are the contributions of obstetrician nurses in childbirth care?The period studied was from January 2010 to December 2015.The descriptors were: nursing and childbirth or obstetric or prenatal care.The sample consisted initially of 45 articles, where only 18 publications obeyed the following criteria: Inclusion criteria: national journals; Indexed in the SciELO database; In the period from 2010 to 2015; full texts, addressing the issue of assistance in prenatal and childbirth by Obstetric nursing.
Exclusion criteria: abstracts or incomplete articles; Outside the period 2010-2015; strange content to the theme studied.
The data collection involved a synoptic table with 6 (six) variables that ensured the transcription of aspects considered more relevant in the articles, such as: title, author or authors, year, main objective of the study, type of study and results.
The analysis of the 18 publications that composed the sample occurred through reading and careful re-reading, as well as a critical analysis of the meaning of the data regarding obstetrical nurse care in prenatal care and delivery.The material was organized into tables, according to the variables studied.Table 1 shows the relation of the selected articles and categories in which they were framed.
Thus, the present study obeyed the methodological steps already described above: A definition of the problem; Selection from the inclusion criteria; A search for literature studies; The collection of data; A critical evaluation of them and finally synthesis of the data.

Analysis of information
In this stage of the Integrative Review of the literature, an analysis of the information was carried out, to be interpreted, on the aspects related to the objectives.Of the 18 papers selected, five articles were from the year 2010 (28.0%), one from the year 2011 (5.6%), two from 2012 (11.0%);Two of 2013 (11.0%);Four in 2014 (22.2%) and four in 2015 (22.2%), which indicates a relative and constant distribution over the years, despite the very small number of studies in this area.
Regarding the distribution of production, this was presented according to Table 2 below.
According to Table 2, the great majority of scientific material produced 13 (72.2%),was an article resulting from original research.These are important contributions and intended to disseminate the results of an unpublished research paper, which has the condition to be replicated and / or generalized.Another 4 (22.2%) were the results of monographs to complete specialization courses and 1 (5.6%) an experience report.
The number of keywords ranged from three to five.More than half of the material selected contained three descriptors.It is important to emphasize that the standardization of the keywords used to identify the selected material in a syntactic way is of great importance for an easier localization of the material.These allow researchers, when in use, to shorten search time.For this, the authors need to make sure that, when selecting the words, try to emphasize those that most characterize the content to be divulged.And, the number of words becomes important, because it represents more options so that you can locate the material you are looking for.
Table 3 below shows a summary of the material selected for analysis.
The categories were inspired by the article of Nunes, Ferreira and Paiva (2002) 39, which deals with the working conditions of the obstetrician nurse,  Therefore, referring to some health practices of the obstetrician nurse, such as childbirth care, pre-natal care and the use of nurse's own strategies and procedures, according to health policy regulations.

Category 1. Prenatal Care
This category encompasses the studies that dealt with aspects of obstetric nursing prenatal care found in the literature, according to the inclusion and exclusion criteria.
Six articles were included in this category (Table 1).Considering that the articles were selected at random, it was observed that the issues related to prenatal care, despite the recognition of the importance of the nurses' work in this dimension of care, they still do not do it effectively, developing all functions, as recommended in the Ministry of Health of the manual that deals with prenatal and postpartum period for a qualified and humanized care.In this case, nurses are still more involved in the actions related to breastfeeding, follow-up of pregnancy and health promotion of pregnant women and children, leaving more important actions such as: verification of the probable day of delivery, vital signs, determination of weight and nutritional status, edema research, uterine height measurements, weight and request for laboratory tests.
The conclusions also indicate that the quality of nursing care would be directly related to its technical capacity to do so.

Category 2. Childbirth Assistance
In this category, eight articles were framed (Table 1), out of the eighteen selected for this study.That represented 44.5% of all articles selected at random.
It will be appreciated by Childbirth Assistance as the subjects related to the set of strategies and means used by obstetric nursing, in order to alleviate pain, bring relief to the mother, or any dispensation of help to her at the time of childbirth .
Articles in this category, emphasized the great importance of the professional nurse presence in assisting women during childbirth.And that proper attention to the laboring woman at delivery would be a major step in the experience of this experience with more tranquility and security, resulting in a higher welfare.
It was concluded that obstetric violence is still a reality during childbirth, although it is not perceived as such by the parturients themselves, in view of being a very significant moment of their lives, loaded with emotional meanings.
This situation, by itself, already predisposes the patient to greater vulnerability, not favoring that the same report on such problem.

Category 3. Nursing strategies and health policies
In this category four articles were framed to discuss aspects related to nursing strategies and public health policies.
Among them, the governance capacity aimed at overcoming organizational difficulties, coupled with expertise of the experience acquired by the professionals, related to the domain of the care environment.It was also concluded by the wide scope of nurses' possibilities for the management of health units.The problematic of the registries was worrisome and problematic, as far as the communication and in the monitoring of the evolution of the patients, contributing in this way to a less valorization and not proof of the nurse's performance.
Other situations verified were: with the small number of articles and papers focused on the legal responsibility of the nurse obstetrician; With a strong emphasis on error prevention in publications, as well as civil and ethical responsibilities; The lack of emphasis on the implications and sanctions, and administrative penalties in these cases.Positions about the need of nurses' instrumentalization on possible legal implications of their actions, was evidenced as important.
The articles also showed the need for a mapping and definition of typologies of violence in childbirth, in order to serve as a basis for public policies to protect women and to prevent obstetric violence, proposing a research agenda in this area.

Discussion
As observed, the field research works, of an exploratory and descriptive nature available on the subject, are scarce in the data base considered.In the work in question, of the 18 articles, only 7 (38.8%)are exploratory field surveys.
This result was already foreseen, since there is still much to invest in the training of the nurse professional, so that it can develop the research culture in their daily work.Nursing schools tend to concentrate more qualified researchers for scientific production, These often act as advisers, which implies in the elaboration of work of conclusion of course.This situation tends to result in a higher index of scientific productions coming from these courses.
Educational services provide the most appropriate environment for the research process.All professions require scientific knowledge for basic training in their professional practice.In this line of reasoning, authors affirm that nursing research is of great importance in improving and expanding new knowledge to strengthen the profession, clarifying concepts and guiding nursing practices.
Another relevant finding was about the year of production.A higher concentration in 2010 (28.0%), decreasing in 2011 to 2013, with 5.6%, 11.0% and 11.0% respectively, once again increasing in 2014 (22.2%),And 2015 (22.2%).It is possible that a greater appreciation of the degree to enrollment in the several newly created federal universities, have stimulated a greater participation of nurses in postgraduation courses.Allied to this, the granting of fellowships in the country for research also increased considerably since the year 2000 [41].
The number of authors that appeared in the studies, showed some congruence with other researches conducted in the country.There was a prevalence of 94.5% of papers published in coauthorship.The number of co-authors ranged from 1 to 7, although most studies, 66.7%, had 2 to 3 co-authors.Therefore, a notorious tendency to carry out research and work in groups, this being an important indicator for the development of quality scientific production in nursing [11].
Nurses were the most prevalent professional category in the studies.The publications on obstetric nursing showed a certain increase in the last two years of the study, since there was a greater incentive for publications of works, as a relevant criterion of the CNPq, in the evaluation of postgraduate pro-grams maintained in the universities.This incentive to research was also present in undergraduate courses, as a support during the training of young doctors.This situation had a positive impact on the scientific production of Latin America as a whole, which showed a significant increase.Importantly, Brazilian researchers surpassed those of other Latin countries, in number of scientific publications [14].
The databases represent effective means of updating.Scientific journals sheltered in such bases, such as SciELO, are consecrated as one of the most popular ways of research [15].
The findings confirmed previous information that confirmed the original articles as the majority of primary sources (72.2%),followed by monographs (22.2%) and experience reports (5.6%).This implies that nurses produce their articles directly for publication.Nurses in general are both consumers and research producers.This fact tends to add value to the growth of quality in nursing services [42].
Nurses were more frequent participants in the research, probably because they represent the professional category that most directly deals with such clientele.It is important to emphasize the great participation of women as targets of obstetric care, in its various stages, from the puerperium, gestation, delivery, as well as in the preoperative period.Such studies are of great relevance when concentrating these populations, since women are more vulnerable in expressing their real feelings, or even the needs that are part of these phases of life.
As for the method, there was a prevalence of qualitative approaches, and concentration on human experience in more natural settings [43].Qualitative information refers to understandings about the perceptions of certain personal experiences of those involved, influenced by culture throughout life [44].By gold side, the quantitative tend to use instruments, which measure measures to ensure certain reliability to the data found.They are based on their quantification and comparison [45].
In quantitative research, the information is more accurate and easier to interpret than in qualitative research [40].
Authors agree that they are the researches with quantitative and qualitative data, essential for the full development of science.There is even greater use of this complementation.The quantitative methods complement the qualitative ones, as they add values to the motives and perceptions of the involved actors, which tend to guide actions to be implemented [46].

Conclusion
The studies demonstrated that the nurse obstetrician, passes through challenging moments in the current political conjuncture.Many professionals do not seem to value the profession.
There was scientific evidence on the importance of promoting an efficient performance of the obstetrician nurse, throughout the cycle of care in pregnancy, from prenatal to puerperium, both technically and humanely, in order to provide greater satisfaction to the Users.Nurses' contributions, cited in this study, are of great value in prenatal and parturition care, providing greater dignity, comfort, support, guidance and care necessary for greater patient autonomy and safety.It is possible that other studies, which contemplate a greater number of databases, may also provide reflections and discussions that will enrich this area of knowledge, supporting and giving greater visibility to the work of the obstetrician nurse.
Adequate hospital care at childbirth should be considered humanized and safe, guaranteeing women all possible benefits arising from scientific and technological advances, as well as stimulating the exercise of maternity, rescuing their autonomy in childbirth, not only By obstetrician nurses, but by all health staff involved with pregnant women and mothers.
The present study also reaffirms the proposals of the World Health Organization for maternal and child health, which establishes, among other orientations, social responsibility with the protection of women and children, in order to provide them with a better quality of life, Extended to all human beings without distinction.International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q2 in category Medicine.

Table 1 .
Distribution of the domains and facets of QoL.João Pessoa, PB, 2015.

Table 2 .
Distribution of scientific output on obstetric nursing, relative to the primary source of the research.SciELO, sept/oct.2016.

Table 3 .
Distribution of the selected material for analysis, according to the variables selected for the study.SciELO, sept./oct.2016.
ReviewIt concluded that the greatest focus of nurses seems to be on breastfeeding actions, and monitoring the evolution of pregnancy, promoting the health of pregnant women and children.This article is available at: www.intarchmed.comand www.medbrary.com6 p.653.