INTRODUCTION

Gestation is a natural process of the female organism that involves in physiological, social and emotional conditions consistent with each stage, and its evolution does not imply unfavorably to the woman and the fetus/newborn. However, when it did, conceptually we have a high-risk facility. The usual classification divides the risk factors in relation to pre-existing conditions and those that manifest throughout pregnancy, conferring responsibilities to health staff at all levels of care, in order to identify early as possible, perform and necessary follow-up, in addition to the development of educational actions directed at individual grievances¹.

Among the risks of gestational risk, it is possible that they may develop in gestation as direct obstetric complications, exemplified by arterial hypertension, hemorrhage, puerperal infection and abortion. On the other hand, there are indirect obstetric causes represented by factors prior to pregnancy and characterized by unfavorable socio-demographic conditions, individual profile, previous reproductive history and preexisting conditions. The first case may lead to direct obstetric maternal death, and in the second one to the indirect death, the hypertension, sepsis and abortion are the most prevalent causes of death in Latin America, especially in the puerperal period ^1)(2)(3.

In order to measure the number of maternal deaths, the Maternal Mortality Ratio (MMR) is used, a quality ratio as direct or indirect obstetric deaths with the number of live newborns. In just over two decades of global incentives and efforts, the RMM decreased from 283.2 to 209.1. In Brazil, considerable political and institutional progress allowed for a rate of decline of about 7 per cent between 2000 and 2010, a figure considered insufficient for a reduction target of 3/4, equivalent to 5.5 per cent annually³⁾⁽⁴.

Faced with this magnitude, as a starting point that the nurse, obstetric nurse, obstetric, nursing specialists and women's health care have as a legal premise their performance as a part of the health team to plan nursing care of pregnant, parturient and regardless of gestational risk classification⁵⁾⁽⁶.

Therefore, nurses, together with other professionals, prioritize prenatal care for risk detection or as early as possible. In the follow-up dynamics of pregnant/puerperal women, they are vigilant for a reclassification of risk at each visit, as well as during labor and throughout the puerperium. For the test, the physical fitness test, the general physical exam, the gynecological examination and the obstetrics, in addition to the educational activities developed individually with a woman, in order to meet the specific needs. They also derive this number of consultations in the primary network, home visits and reference for the use of professional and technological resources of the secondary and tertiary levels.

In view of this, it is necessary to know the scientific production on nursing care provided to women of high risk severity in order to draw a panorama of knowledge produced towards the contribution that it offers to the fulfillment of the fifth goal for the development of the Millennium

Therefore, it became an objective to analyze the perspectives of nursing care for women who experienced a high risk pregnancy from international and national scientific production.

MATERIAL AND METHOD

In view of the objective proposed, the integrative review method was used as a method to establish summaries and conclusive considerations about a given theme in order to identify the contributions, gaps and limitations of the studies developed in the established temporal cut-off. It is an important instrument for professional practice, since it groups, in a systematic way, specific researches in an area of ​​knowledge⁷.

To do so, it prescinds the operationalization of stages, which were applied in this study: elaboration of the problem/question of the revision; establishment of inclusion and exclusion criteria; data collection and evaluation; analysis and interpretation of the data; presentation of results⁷.

The topic considered for this review was high risk gestation, asking: what knowledge has been produced by nurses about nursing care to women who have a gestation classified as high risk?

The inclusion criteria included research papers which were published in international and national journals; in Portuguese, English, Spanish and French. The time cut was from 2000 to 2014. This initial milestone was due to the fact that this was the year of the commitment to reduce the maternal mortality ratio (MMR) by three quarters between the World Health Organization and 141 countries. We included indexed studies in databases, with abstracts and full texts available online. Articles written only by non-nurses as well as repetitive ones were excluded, considering only once.

The searches were conducted between August/2015 and September/2015 on the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature on Line (MEDLINE), Latin American and Caribbean Literature (LILACS) and Database (BDENF), through the combination of the descriptors and the Boolean AND, which privileged the association between the pathophysiological issue of interest (high risk pregnancy) in the intended care/professional plan (obstetric nursing, nursing care) considering the Thematic area (women's health) in Portuguese and English.

There were 790 articles. After application of the inclusion criteria for temporal, idiomatic, repetition, incompleteness and thematic clipping, 764 studies were excluded. The integral readings of the texts were carried out in a floating way at first, and then in a more profound and critical way. Finally, it concentrated on 24 studies, 14 of them are national and 10 ones are international.

Among the procedures used to extract the studies listed, a validated instrument⁸ was used to systematize tables containing the titles of productions, authors and their formations, periodicals, country of origin, language of publication, descriptors, objectives, theoretical framework, research design, research development scenario, sample, period and instrument of data collection, method and data analysis, attention to ethical issues, main results and conclusions, limitations and levels of evidence⁹.

Concomitant to the preparation of the tables, the studies were evaluated independently by peers through careful observation of cohesion, textual coherence and consistency, and methodical steps, as well as articulation between them with the results discussed and conclusions pointed out. The critical analysis about the pertinence and inherence of the texts considered 24 studies, allowing the emergence of two categories: Nursing care in the perspective of the subjectivity of the woman who experiences the high risk gestation; Care for the woman who experiences the high risk gestation from the perspective of the systematization of nursing care.

The interpretation of the conclusions of the manuscripts resulted in recommendations for the assistance practice and for the development of new investigations from the gaps found. Finally, the synthesis of the produced and published evidences was elaborated.

RESULTS

It was verified that 58% (14) of the articles were published in national journals and 42% (10) in international journals. The countries of the studies were divided into the United States, Canada, Australia, Taiwan and Colombia.

As for the year of publication, most of them were published in 2007 (21%), 2004 (13%) and 2013 (13%).

The selected studies were classified according to their category of publication, as reported in the journals, as specified: 81.8% (20) original research, 4.6% (1) documentary research, 4.6% (1) studies of systematic review of the literature and 9% (2) articles of reflection.

Among the 14 national articles analyzed, six covered the gestation of risk, six explained the Specific Hypertensive Disease of Gestation and two the gestational diabetes as an investigative object. Qualitative designs predominated (eight publications) followed by two quantitative studies. Among the references based on nursing theorists there were those which were written by King and Orem. The use of the theory of social representations and phenomenology was also observed.

The international searches were similar to the national ones in relation to the investigative interest with eight articles that dealt with the general gestation of risk followed by one that specifically addressed the premature rupture of membranes and another one that approached the pre-eclampsia. In consideration of the research design, five studies were qualitative, one is anchored in phenomenology; Five are quantitative. Table 1 summarizes the distribution of the articles with their main conclusions.

DISCUSSION

Nursing care from the perspective of the subjectivity of women who experience high risk pregnancies

The majority of researches were concerned with the understanding of the subjective aspects of the pregnant women, revealing them a little considered by the nurses, despite the technical advance in the management of clinical situations under strong biomedical influence¹⁰.

In this context, a relevant issue focuses on the increasing tendency of gestation over 35 years-old, associating this with chronic pathologies such as diabetes and hypertension, among others that contribute for many of the undesirable statistical outcomes. Above 42 years-old, the probability of fetal death is 50% and spontaneous abortion is more than 70% ¹¹.

However, along with the demands of physiological aspect, the socio-psycho-spiritual dimensions were strong, since the association between GHD and negative feelings has been described. Exemplary of these feelings were anxiety, suffering, doubt, fear due to the condition of prematurity of the concept and guilt for not following the medical advice regarding feeding and rest during gestation. Since the identification of the risk diagnosis, stress and anxiety were present in the daily life of the patient and her relatives, implying greater vulnerability during the puerperal pregnancy cycle¹².

Through the Social Representations Theory, it was detected that the perception of the severity of the risk by the pregnant woman only occurred when referring to a service of greater complexity or before the hospitalization, denoting poor understanding or lack of information/orientation to the patients during the prenatal care. Thereafter, unfavorable feelings were aggravated by ineffectively implicating therapy in reducing blood pressure¹³.

It is mentioned that in this context, it should be considered that the issues of interpersonal relationship in the domestic world of women also influence it aggravating or triggering clinical manifestations of varying intensity. It should be noted that hospitalizations produce a separation of the home environment and contribute to the reduction of the loss of autonomy of the woman, although in some cases it is seen as an important moment of recovery of health and maintenance / termination of pregnancy¹⁴.

During hospital stay, women with hypertensive disease experience increased levels of stress, especially in the last week before delivery. Not only in the case of DHEG, but in all pregnancies classified as high risk, it is pointed out the need to combine efforts between the patient and health professionals towards the best possible results through the exchange of information and perceptions by all those people involved in the decision-making process^15)-(16.

In fact, by listening attentively to the voices of pregnant women classified as high-risk hospitalized in the pre-delivery unit, it can be shown that being at rest "absolute" stresses and gives depressive feelings related to anxiety and boredom, as well as somatic complaints. This problematic condition is confirmed by the results of 180 interviews which showed that the higher the levels of stress and anxiety, the lower the levels of spiritual well-being, and that integral health is strongly linked to the therapeutic access and consideration of the psychic and social, emotional and spiritual dimensions. Therefore, encouraging women to talk about themselves and, on the other hand, being available to listen to them, enables the nurse to outline the planning of stress-reducing actions, thus minimizing the consequent discomforts of mind-body-spirit disharmony^17)-(18.

When considering the psychological impact of pregnant women who were informed in the first trimester about the high risk of developing preeclampsia, the results revealed a high sense of internal control, information search strategies and behavioral changes, indicating their efforts towards to minimize the risk¹⁹.

At the same time, integrality as a principle of the Unified Health System (SUS) /Brazil highlights the appreciation of the educational process carried out in an inter-subjective way, which undermines the doubts and desires of pregnant women, as well as enabling them for the early identification of new crises. In this perspective, during the hospital stay, diabetic pregnant women revealed that the possibility of being a mother, even in the risk situation, with previous histories of abortion and medical interruption of pregnancy, conferred them happiness and well-being. By sharing their positive and negative feelings with the health team, they felt heard and credited by the professionals, minimizing the emotional repercussions of being away from their families²⁰.

The reflection about the phenomenological studies that tried to understand the woman who experienced the high risk pregnancy considered that the approach of the nurses to the needs of the pregnant-puerperal woman allowed the critical thinking and consequent directing of the nursing care to the being-care²¹.

Thirteen couples from two obstetric units in Taiwan were investigated in order to understand the transition of the maternal role under the condition of stress motivated by the gestational risk of premature rupture of membranes (PROM). From the cultural understanding of family values ​​and the strong paternal relationship, the study provided important results for the clinical practice of Chinese nurses. Given the risk of PROM, the professional approach should consider establishing a bond with the client and her family that translates trust and support to them²².

In this sense, the human dimension of spirituality, which is "deeply personal, universal and inherent in the experience of high-risk gestation," is also considered important. Research carried out with 12 pregnant women hospitalized at the Canadian prenatal unit identified their values, perceptions and spiritual practices. According to the deponents, the habit of prayer and other resources congruent with their beliefs, especially in moments of greater fear, anguish and uncertainty, conferred the calm and comfort that no other intervention or even the presence of relatives and friends were able to provide^{23)(24)(25)(26)(27}.

Thus, the scientific positions that revealed the nursing care from the perspective of the subjectivity of women who experience high-risk pregnancies, invite nurses who assist the pregnant woman from the prenatal period to identify the bio-psycho-socio-spiritual peculiarities of each patient, valuing their way of thinking and giving spaces in which the exchange of information and the provision of guidelines can occur with greater effectiveness.

Care for women who experience high-risk pregnancies from the perspective of the systematization of nursing care

The international researches that dealt with the process of caring in nursing to the high risk pregnant women gave in the everyday work possibilities to think about the interventions implemented from new models of care, as emphasized the study developed with a thousand women in Australian maternity. In this clinical trial, the group of women with gestations classified as at risk received interventions through an individualized care plan developed in multi-professional consultation with obstetricians and nurses. The study found an increase in the level of satisfaction of women in relation to the continuity of care in the peripartum period by the same professional, with a greater impact on prenatal care²⁴.

At another locus of the health system in the United States of America, the efficacy and efficiency of outpatient nursing interventions directed at pregnant women at risk of preterm delivery were evidenced. More than 90% of the episodes of increased uterine contractions or other symptoms were solved by nursing prescriptions without the need for hospitalization, demonstrating the value of the Interventions of the Advanced Nursing Practice (APN - similar to the Nursing Process - PE - in Brazil) in secondary care and its direct influence on the reduction of government costs²⁵.

In this conception, the pre and postpartum problems of 85 pregnant women at risk, as well as the corresponding NPC interventions, were described. The physiological aspects had about 60% of the problems evidenced against 33% of health-related behavioral problems. Regarding the quantitative of interventions, about 70% occurred in the prenatal and only 28% in the puerperium, denoting efficacy of the activities most commonly prescribed during pregnancy, such as surveillance, health education, counseling and guiding interventions in the cycle Puerperal pregnancy²⁶.

The results of the national surveys also pointed to evidence of nursing care in high-risk gestation from the Nursing Process elaboration. However, in nursing scientific publications about high-risk gestation, SAE (systematization of nursing care) have been considered a relevant object of research by attending to the patient with Specific Hypertensive Syndrome of Gestation (SHEG), which indicates a certain reductionism.

From this perspective, it is pointed out that the high prevalence of SHEG requires nurses to have adequate knowledge to assist the patient in the various scenarios in which they find themselves, whether of small, medium or high complexity. The effectiveness of the nursing consultation is evidenced by the early recognition of signs and symptoms that may endanger the life of the mother and child, as well as educational guidelines and referrals that may prove necessary²⁷.

A case study was carried out to identify nursing diagnoses in pregnant women at risk, based on Dorothea Orem's theory of self-care, considering home visits before delivery and, when in the puerperium, hospital visits. Self-care deficits and diagnoses related to fluid ingestion, safety, lifestyle, communication, skin integrity, protection, knowledge, hygiene, elimination and comfort were pointed out²⁸.

In another sense, the most common nursing diagnoses were presented in 71 hospitalized risk women: altered health and comfort maintenance, risk for ineffective breastfeeding, risk for infection, fear, pain and disturbance in the sleep pattern. Concerning the collaborative problems, preterm labor, maternal tachycardia, hypotension and fetal distress have predominated²⁹.

Considering the assertions about SAE applied to 15 pregnant women with hypertensive disease, we listed as diagnosis the risk of infection, acute pain, low situational self-esteem, excessive fluid volume, nausea, sleep deprivation, impaired liver function risk, impaired urinary elimination, constipation, unbalanced nutrition and anxiety. The prescription of nursing care focused on technical activities, focusing on the monitoring of signs and symptoms with assessment of body parameters through physical examination, administration of medications and provision of guidelines to study participants³⁰.

With regard to the latter, research focuses on the educational dimension as an activity that provides openness to talk about itself. In these, the nurse must offer emotional and educational support during all moments of care during the gestation, delivery and puerperium in order to guarantee the well-being of the woman and her relatives. Whether individual or in a group, the exchange of experiences, the free expression of feelings, the possibility of reflecting with the professional about situations involving risk pregnancy, allowed a better coping of this condition, in which the pregnant / puerperal woman occupies a prominent place^{31) -(32}.

In parallel, when considering gestational diabetes mellitus from the perspective of 50 women affected by the disease, health care in the prenatal period was below the intended level. Procedures such as non-measurement of blood pressure and blood glucose, and lack of verification of uterine height revealed the unprepared professionals. It should be pointed out that the aforementioned participants had, in their majority, an association of the underlying pathology with arterial hypertension³³.

It is noteworthy that, despite the fact that SAE is considered relevant to the risk condition in the pregnancy-puerperal cycle, the reports made available to the scientific community are limited because they do not address the specific causes of the risk, and when they do, they address expressive mode to DHEG. In addition, it is convenient to reflect on the biologicist focus of nursing research, emphasizing diagnoses and interventions that are mostly of a physiological nature, with less emphasis on social, psychic and emotional aspects, important influencers of the gestational course.

CONCLUSION

The analysis of the international and national nursing scientific productions about the high risk gestation theme indicated that the studies carried out since 2000 as responses to mobilization to reduce maternal morbimortality showed a concern with the perceptions and meanings of gestating in the condition of women and their families; and the development of the Nursing Process.

International research has advanced to interventions or advanced nursing practice, with an eminently prescriptive focus on prenatal care through the monitoring of pregnant women at risk and health guidelines. National surveys, although they looked at the associations between pregnancies and their negative feelings, were related to the specificity of the Specific Hypertensive Disease of Gestation. In contrast, international research has broadened the causal aspect and advanced the discussion about spirituality and the ability to generate well-being and resolve anxiety.

Regarding the nursing care process directed to high risk pregnant women, the synthesis of the Brazilian studies showed the direction of the nurses' eyes for SAE, specifically in the clinical trial stage of the responses of pregnant hypertensive patients, culminating in the elaboration of the diagnoses of nursing. These, for the most part, expressed physical discomforts. Educational intentions with openings for the pregnant woman to speak of themselves, although small, were also evidenced.

In fact, assistance to high-risk pregnant women requires professional qualification, skill and effectiveness in the management of emergency or potentially complicating situations during the puerperal pregnancy cycle. The nurse assists her at all levels of the health system, including during examinations that collaborate with the diagnostic accuracy. However, it is noteworthy that in spite of the mention of some activities of orientation to the pregnant woman and of the reception of the psycho-emotional manifestations, the technical guidelines are expressively centered on the assistance of the physician with a strong medicalizing tendency.

Regarding the gaps observed with this Integrative Review, it is pointed out that part of the national studies delineated the meanings of high-risk gestation for the woman who experiences it, which is a peculiar moment of anxiety, fear, guilt and uncertainties. These meanings are valuable indications, answers that should guide interventions to reach the being of who cares. However, on the other hand, studies about nursing care processes focused their prescriptions on the physiological aspects, which are close to the biomedical paradigm and far from the pregnant woman at risk.

This polarity announces the need to develop care methodologies in which the nurse directs the attention to the appreciation of the multifaceted dimensions of the pregnant woman, considering her as she feels despite the risk situation. So, the articulation between the stages of the nursing process will show not only the knowledge and skills inherent to the nurse and the care itself, but especially the attitudes that will reveal the interactive and humanistic essence of the profession