Abstract

Introduction: Given the intense medicalization of childbirth and the hegemony of a technocratic model, there is a growing need for professional midwives to promote safe pregnancy and childbirth with minimal interventions. Objective: This study aims to identify the technologies present in the toolbox of certified midwives graduated from University of São Paulo. Methodology: It consists of a descriptive-exploratory study, with a qualitative approach. Semi-structured interviews were carried out virtually with five midwives from August 2020 to May 2021. The material was analyzed using dialogical maps. Results: A very heterogeneous range of technologies was identified, which included soft, soft-hard, and hard technologies. Soft technologies include affection, effective communication (knowing how to speak, knowing how to listen), and bonding. Soft-hard technologies include basic disciplines, scientific evidence, experience, and intuition. Finally, hard technologies include human-made instruments, in addition to the use of the materiality of the body. Conclusions: Midwives tend to use hard technologies when they are unable to achieve the desired effect with the soft technologies they had available, while also using their interrelational resources throughout the entire process. Furthermore, to employ such technological resources, professionals use different kinds of knowledge, without hierarchizing them.

Keywords:
Low cost technology; Home childbirth; Humanizing Delivery; Midwifery

Introduction

¹1Financing: Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Process No. 140189/2018-1.

Since the 1950s, the World Health Organization (WHO, ¹⁹⁵⁵OMS – ORGANIZAÇÃO MUNDIAL DE SAÚDE. Expert Committee on Midwifery Training: first report. OMS: Genebra, 1955. Technical Reports Series. n. 93. ) has recognized the importance of training professionals responsible for childbirth care who are compassionate and, despite their universal technical skills, sensitive to sociohistorical and cultural specificities in order to use the resources at their disposal properly and effectively. The history of modern obstetrics, however, has led to the hegemony of a model highly focused on hard technologies, which can only be wielded by medical authorities in places far removed from the homes and communities of women in labor: the hospital (Davis-Floyd, ²⁰⁰¹DAVIS-FLOYD, R. The technocratic, humanistic, and holistic paradigms of childbirth. International Journal of Gynecology & Obstetrics, London, v. 75, n. 5, p. 5-23, 2001. DOI: 10.1016/S0020-7292(01)00510-0
https://doi.org/10.1016/S0020-7292(01)00... ; Spink, ²⁰¹³SPINK, M. J. P. As origens históricas da obstetrícia moderna. In: SPINK, M. J. P. Psicologia social e saúde: práticas, saberes e sentidos. 9. ed. Petrópolis: Vozes, 2013. p. 169-193. ; Mott, ²⁰⁰²MOTT, M. L. Assistência ao parto: do domicílio ao hospital (1830-1960). Projeto História, São Paulo, v. 25, p. 197-219, 2002. ).

Thus reducing the obstacles and allowing women to be subjected to all sorts of interventions for the convenience of doctors and the hospital. As Diniz ( ²⁰⁰¹DINIZ, C. S. G. Entre a técnica e os direitos humanos: possibilidades e limites das propostas de humanização do parto. 2001. Tese (Doutorado em Medicina Preventiva) – Faculdade de Medicina, Universidade de São Paulo, São Paulo, 2001. ) points out, as early as the second half of the 20th century, there was a rapid expansion in the use of technologies aimed at controlling labor, which, to this day, perform the functions of monitoring, triggering, regulating, or accelerating the parturition process. In addition to resources such as synthetic oxytocin, cesarean sections are abundant in Brazil. In 2021, around 58% of all births took place surgically (Brasil, ²⁰²³BRASIL. Datasus: Departamento de informática do SUS. Informações de saúde: nascidos vivos. Brasília, DF: Ministério da Sáude, 2023. ), while rates of more than 10-15% are not justified (WHO, ¹⁹⁸⁵OMS – ORGANIZAÇÃO MUNDIAL DE SAÚDE. Appropriate technology for birth. Lancet, London, v. 326, n. 8452, p. 436-437, 1985. DOI: 10.1016/S0140-6736(85)92750-3
https://doi.org/10.1016/S0140-6736(85)92... ).

According to Davis-Floyd ( ²⁰⁰¹DAVIS-FLOYD, R. The technocratic, humanistic, and holistic paradigms of childbirth. International Journal of Gynecology & Obstetrics, London, v. 75, n. 5, p. 5-23, 2001. DOI: 10.1016/S0020-7292(01)00510-0
https://doi.org/10.1016/S0020-7292(01)00... ), given the hegemony of the technocratic model and the excesses of technomedicine, a humanist perspective is emerging, which seeks to humanize medicine and obstetrics, making them relational, partnership-oriented, and compassionate, without renouncing the use of technology. In the context of care, the role of trained professionals stands out—whether they are nurse midwives or midwives—in implementing a model of childbirth care that has been recommended by the WHO for more than 70 years This model is defined by the provision of safe care, with as few interventions as possible and the appropriate use of available technologies. As the United Nations Population Fund (UNFPA, ²⁰⁰⁶ UNFPA – UNITED NATIONS POPULATION FUND. Towards MDG 5: Scaling up the capacity of midwives to reduce maternal mortality and morbidity. New York: UNFPA, 2006. ) points out, when trained properly and in accordance with evidence-based recommendations, nurse midwives and midwives are key to reducing maternal and infant mortality indicators, guaranteeing sexual and reproductive rights, and also reducing the excessive medicalization of pregnancy and childbirth.

In Brazil, the majority of graduate midwives are trained by specializing in Midwifery after graduating in Nursing. However, since 2005, the possibility of another training route has been reopened. Linked to the School of Arts, Sciences and Humanities at the University of São Paulo, the Midwifery course trains professionals qualified in the art and craft of midwifery through direct entry to university, reviving the same training model as the School of Midwives of São Paulo, which was attached to the Faculty of Medicine at the University of São Paulo until 1971 (Riesco; Tsunechiro; Leister, ²⁰⁰²RIESCO, M. L. G; TSUNECHIRO, M. A. Formação profissional de obstetrizes e enfermeiras obstétricas: velhos problemas ou novas possibilidades? Revista Estudos Feministas, v. 10, n. 2, p. 449-459, 2002. DOI: 10.1590/S0104-026X2002000200014
https://doi.org/10.1590/S0104-026X200200... ). In this context, from the extinction of the School of Midwives until the reopening of the midwifery course, the only possible route for training midwives in Brazil was a degree in nursing, which contrasts with the tradition of training midwives in direct entry courses, common in Europe (Riesco; Tsunechiro, ²⁰⁰²RIESCO, M. L. G; TSUNECHIRO, M. A. Formação profissional de obstetrizes e enfermeiras obstétricas: velhos problemas ou novas possibilidades? Revista Estudos Feministas, v. 10, n. 2, p. 449-459, 2002. DOI: 10.1590/S0104-026X2002000200014
https://doi.org/10.1590/S0104-026X200200... ).

According to its Pedagogical Political Project (EACH, ²⁰¹⁷ EACH – ESCOLA DE ARTES, CIÊNCIAS E HUMANIDADES DA UNIVERSIDADE DE SÃO PAULO. Projeto político pedagógico curso de graduação em obstetrícia. São Paulo, 2017. Disponível em: http://www5.each.usp.br/wp-content/uploads/2015/11/PPP-Obstetr%C3%ADcia-2017.pdf . Acesso em: 3 out. 2023.
http://www5.each.usp.br/wp-content/uploa... ), the Midwifery course is structured in accordance with the recommendations of the WHO and the International Confederation of Midwives (ICM). This implies training professionals capable of working in the field of education and promotion of sexual and reproductive health, with a special focus on care during pregnancy and childbirth. In childbirth care, midwives must be able to use technology appropriately.

Based on the guiding question “what technologies do midwives have at their disposal in order to act according to their goals during labor management?” we sought to identify the tools present in the toolbox of midwives who graduated from the Midwifery course at the University of São Paulo (USP). We used the notion of technological toolbox as a theoretical reference (MERHY, 200), taking into account that technologies can be of three different types: soft, soft-hard, and hard. The first relate to the relational space between the caregiver and the person being cared for. Soft-hard technologies, in turn, are the structured knowledge that underpins the decision-making and action process. Finally, the latter include equipment and other instruments endowed with materiality, and are closely linked to the hands of these professionals.

Methodology

The research that resulted in this article is qualitative, descriptive, and exploratory. The interviewees were selected from a list of ten urban midwives provided by a key informant, our first interviewee. The inclusion criteria were training in Midwifery and working in planned home births in the capital of São Paulo. Those who were not available to take part in the research within the time frame stipulated for collecting the information to be analyzed later were excluded. Also due to this schedule, additional contacts were not made with other professionals and, therefore, the recruitment of new participants was discontinued. The initial approach was made via messaging app (WhatsApp) and the interviews were conducted between May and August 2021, after approval from the Research Ethics Committee of the Pontifícia Universidade Católica de São Paulo, obtained in May 2020 (CAAE: 30829520.5.0000.5482, opinion no. 4.031.049).

A semi-structured script was used as a basis. Carrying them out in this way allowed us to guarantee a certain amount of freedom when asking and answering questions, which provided moments of “construction, negotiation, and transformation of meanings,” as advocated by Aragaki et al. ( ²⁰¹⁴ARAGAKI, S. S. et al. Entrevistas: negociando sentidos e coproduzindo versões de realidade. In: A produção de informação na pesquisa social: compartilhando ferramentas. SPINK, Mary Jane; BRIGAGÃO, Jacqueline; NASCIMENTO, Vanda; CORDEIRO, Mariana. (Org.). Rio de Janeiro: Centro Edelstein de Pesquisas Sociais, 2014. , p. 62, free translation). In addition to requesting an initial characterization of the training they had received and the field of work they were in, the script used included questions about the interventions these professionals usually carry out to achieve the necessary ends during labor, the tools they have at their disposal to intervene in the process and the knowledge that underpins their decision-making and action, covered in the following questions: (1) what are the principles that guide your practice?; (2) how do you decide that it is time to intervene in childbirth; (3) what technologies do you usually use?; (4) what knowledge or sources of knowledge do you use to assess the situation that requires intervention?; What underpins the decision-making and action process?; (5) in relation to women giving birth, what is the negotiation process like when you identify the need for intervention?

Considering the pandemic period and the physical distancing guideline, the meetings took place in a virtual environment (via the Google Meet platform) and were conducted exclusively by the first author of this article. At the beginning of each meeting, an informed consent form was presented and, in accordance with Resolution 510/2016 of the National Health Council (CNS), consent was obtained verbally. The online meetings were recorded for later transcription. Each one lasted an average of one hour and comprised only the researcher responsible for conducting the interviews and the professional being interviewed.

After transcribing the content, we used dialogical maps, a tool from the field of social psychology (Spink; Medrado, ²⁰¹³SPINK, M. J. P.; MEDRADO, B. Produção de sentido no cotidiano: uma abordagem teórico-metodológica para análise das práticas discursivas. In: SPINK, M. J. P. (Org.). Práticas discursivas e produção de sentidos no cotidiano: aproximações teóricas e metodológicas. São Paulo: Cortez, 2013. p. 22-41. ), to aggregate the statements about the technological resources used in planned home birth (PHB) care into predefined categories in the light of the theoretical contribution on technologies in health work (Mehry, ²⁰⁰⁰MERHY, E. E. Um ensaio sobre o médico e suas valises tecnológicas: contribuições para compreender as reestruturações produtivas do setor Saúde. Interface, Botucatu, v. 4, n. 6, p.109-116, 2000. DOI: 10.1590/S1414-32832000000100009
https://doi.org/10.1590/S1414-3283200000... ), which are: soft technologies, soft-hard technologies, and hard technologies.

Results and discussion

Before proceeding to present the discursive analysis, it is worth highlighting some of the characteristics of the research participants. In view of our inclusion criteria, they all had higher education in Midwifery, and two of them also had a master’s degree. All the interviewees were women and lived in the city of São Paulo, which demonstrates a perpetuation over time of the profile prevalent among people graduating from the Midwifery course described by Trintinália ( ²⁰¹¹ TRINTINÁLIA, M. M. J. Caracterização e inserção profissional de egressos do curso de graduação em obstetrícia da Universidade de São Paulo. 2011. 164 f. Dissertação (Mestrado) – Universidade de São Paulo, São Paulo, 2011. Disponível em: http://www.teses.usp.br/teses/disponiveis/7/7141/tde-17082011-103213/. Acesso em: 24 abr. 2024.
http://www.teses.usp.br/teses/disponivei... ). The majority of those interviewed were White (60%). In addition, they all recognized their status as agents of a movement to humanize childbirth. In order to preserve the professional-statement relationship and confidentiality, we have only used the initials of the midwives interviewed. The statements, grouped according to the categories defined, are presented below.

Soft technologies: welcoming, knowing how to talk and knowing how to listen

For the midwives interviewed, communication was one of their first responses regarding the technologies they use during labor. Relational in nature (Mehry, ²⁰⁰⁰MERHY, E. E. Um ensaio sobre o médico e suas valises tecnológicas: contribuições para compreender as reestruturações produtivas do setor Saúde. Interface, Botucatu, v. 4, n. 6, p.109-116, 2000. DOI: 10.1590/S1414-32832000000100009
https://doi.org/10.1590/S1414-3283200000... ), this tool plays a key role in identifying the demands and needs of women and parturients.

In this sense, the act of communicating with the woman and person giving birth should be understood as a process of exchange through which midwives interfere in the process. The professionals understand that this dynamic is the main instrument they have at their disposal to meet demands, identify needs, and clearly inform what is happening.

It should be emphasized that communication can change the terms with which parturient women can make sense of their childbirth experience, interfering in the way women experience this moment, making the experience more positive or not.

The gesture of communication is sometimes referred to as a dialog. The use of this term can be understood as an attempt to make sense of communication as an inter-relational process of exchange between subjects with transformative potential, distancing these professionals from conceptions that reduce communication to the transmission of information. It is therefore recognized that dialogue is the first form of effective intervention since childbirth can be understood as a constant process of convincing.

With regard to dialog, it is also argued that it is through dialog that a relationship of trust is established between the woman and the parturient, facilitating the negotiation process in cases of interventions that, at first, are not desired but become necessary. In this sense, open communication about the possible need for interventions throughout the gestational period is key for the midwife’s intrapartum work and for women to have a positive experience, even in cases where more invasive interventions are necessary, especially in the management of urgencies and emergencies.

Ultimately, the adequate communication of accumulated knowledge about what happens to the parturient body is seen as a sine qua non condition for women and other people experiencing this process to be subject to the care offered. This results in a shift in the axis of power in the care offered, including with regard to decision-making and control of the process. However, it must be emphasized that, for midwives, empowerment and self-determination are only possible in a context where every choice is based on quality information provided by professionals.

Recognizing themselves as part of the humanization movement, these professionals’ stance reflects the idea that humanizing childbirth involves both welcoming and respectful treatment and respect for the rights to information and self-determination, highlighting the polysemic nature of the humanization movement pointed out by Diniz (2005).

Hard technologies: the body as an instrument and the instrument in the body

When soft technologies alone do not achieve the goal of guaranteeing the physiological progress of labor, professionals move towards the use of harder technologies to intervene in labor, those which, according to Merhy’s ( ²⁰⁰⁰MERHY, E. E. Um ensaio sobre o médico e suas valises tecnológicas: contribuições para compreender as reestruturações produtivas do setor Saúde. Interface, Botucatu, v. 4, n. 6, p.109-116, 2000. DOI: 10.1590/S1414-32832000000100009
https://doi.org/10.1590/S1414-3283200000... ) definition, are endowed with materiality.

Here, the materiality reported as a tool for conducting labor does not completely fit Merhy’s ( ²⁰⁰⁰MERHY, E. E. Um ensaio sobre o médico e suas valises tecnológicas: contribuições para compreender as reestruturações produtivas do setor Saúde. Interface, Botucatu, v. 4, n. 6, p.109-116, 2000. DOI: 10.1590/S1414-32832000000100009
https://doi.org/10.1590/S1414-3283200000... ) definition of hard technologies as instruments that involve what he called “dead labor” in their production process. The tool they are referring to concerns the use of the materiality of the woman’s or parturient person’s body through specific exercises and positions, using anatomy in favor of the parturition process.

With regard to the use of the materiality of the parturient body during labor, the professionals refer to the method called Spinning Babies , created by American midwife Gail Tully. The purpose of the approach is to offer a third perspective on the dichotomy between technology and nature in childbirth, since, according to the creator of the method, the two need not be mutually exclusive ²2 Available from: https://www.spinningbabies.com/about/what-is-spinning-babies/ . Access on: July 2, 2024. . It is therefore a question of using the materiality of nature itself as a tool for intervention in childbirth, working with the body in new ways. For our interviewees, the aim is to use the body of the baby and of the woman/person in the process of giving birth, before resorting to other hard technologies.

However, it’s not just the materiality of the parturient body that goes into these professionals’ toolbox as instruments of intervention, but also the materiality of their own bodies. With their hands, midwives can intervene in childbirth in a wide variety of ways. The professionals mention that touch is one of the most used interventions in labor, bringing a sense of affection that gives women resources to deal with the prolonged rhythmic pain.

In this context, touch is the physical contact between midwife and parturient used as a strategy to provide the woman with physical and emotional support. However, midwives also use their hands to perform other types of procedures. One of these is the manual reduction of the cervix, the use of which is very controversial in the field of humanization. In this regard, G. points out that the hands are one of the most versatile and important instruments in her work:

In addition, the midwife’s hand will be the first resource used to perform maneuvers in cases of shoulder dystocia and postpartum hemorrhage due to uterine hypotonia. In contexts where there is freedom to give birth in non-supine positions, the algorithm A SAIDA ³3 The mnemonic A SAIDA consists of A = ask for help, acquaint the mother, augment the squat; S = suprapubic pressure; A = alter the position to all fours (Gaskin maneuver); I = internal maneuvers (Rubin II, Wood, inverted spin); D = deliver the posterior arm; A = assess the need for rescue maneuvers. With the first three maneuvers, the authors have achieved the conceptus delivery in 90% of the cases. (Amorim et al., 2013 ) recommends that the parturient’s body be used to facilitate detachment, resorting to manual maneuvers if necessary (Amorim, et al., ²⁰¹³AMORIM, M. M. R. et al. Distócia de ombro: proposta de um novo algoritmo para conduta em partos em posições não supinas. Revista Femina, Rio de Janeiro, v. 41, n. 3, p.115-124, 2013. ). To control bleeding, the first instruments used by midwives are their hands, to perform uterine massage and bimanual compression of the uterus.

If these strategies don’t work, the materiality of the body is associated with other hard technologies. To control bleeding due to uterine hypotonia, for example, oxytocin and other drugs are administered. In this sense, other hard technologies are employed, such as the use of uterotonic substances in the third period, in order to prevent bleeding.

Even so, the use of hard technologies is not restricted to the management of urgencies and emergencies. The midwives interviewed say that they also use them to manage labor, if the attempts with softer technologies have not achieved their goal. In this sense, they argue that, if they consider it necessary, they can resort to artificial rupture of the amniotic sac membranes, also known as amniotomy, a procedure carried out with a specific sterile instrument called an amniotome. Although there is a recommendation that amniotomy should not be used alone in the management of labor, only in combination with oxytocin (WHO, ²⁰¹⁸ OMS – ORGANIZAÇÃO MUNDIAL DE SAÚDE. WHO recommendations: intrapartum care for a positive childbirth experience. Genebra: WHO, 2018. ), the home context ends up allowing some procedures to be carried out before the use of drugs such as synthetic oxytocin, given that, in this case, the parturient should be referred to plan B: her reference hospital.

Therefore, in addition to the materiality of the body, there are many of the midwife’s tools that fit Merhy’s ( ²⁰⁰⁰MERHY, E. E. Um ensaio sobre o médico e suas valises tecnológicas: contribuições para compreender as reestruturações produtivas do setor Saúde. Interface, Botucatu, v. 4, n. 6, p.109-116, 2000. DOI: 10.1590/S1414-32832000000100009
https://doi.org/10.1590/S1414-3283200000... ) traditional definition of hard technologies. These professionals also carry their toolboxes to the birth, in the literal sense.

Some of the interventions mentioned by the midwives involve the use of hard technologies that require transfer to hospital if the birth is taking place at home, whose prescription is not the prerogative of midwives and nurse-midwives. These interventions may be necessary both to manage urgencies and emergencies, such as bleeding that is difficult to control, and to manage labor. One such case is the use of oxytocin. The midwives say that this is, in fact, one of the possibilities, always arguing that resources like this are used in cases of real need.

Among the technologies mentioned whose use is not the prerogative of certified midwives are vacuum extractors, forceps, analgesia, and cesarean sections. As long as these are used when necessary, they understand that they are not prohibited in humanized childbirth. In this sense, midwives reported using less invasive resources before resorting to these interventions, but that they are not ruled out. The point is that they presuppose teamwork, which is not possible in home births.

Finally, the interviewees understood that hard technologies do not replace soft technologies: in other words, instruments and procedures are used in a complementary way to the relational resources they have at their disposal to ensure the smooth running of labor. In this sense, the following case illustrates how the use of soft technologies can guarantee the expected result when using hard technologies after transfer to hospital:

The situation described above is part of a context in which the parturient woman needed to use her bodily strength to make the instrumental delivery a success, but was terrified during the expulsive period. Given the need for the parturient and the qualified professional to work together to perform vacuum extraction, the use of soft technologies was key to the effectiveness of the hard technology.

Soft-hard technologies: between structured knowledge and other legitimate forms of knowledge production

If we only look at soft and hard technologies, some questions remain unanswered. For example, how do midwives know which type of exercise to use or when? How do they detect situations in which a cesarean section is necessary, such as cephalopelvic disproportion? In this respect, Merhy ( ²⁰⁰⁰MERHY, E. E. Um ensaio sobre o médico e suas valises tecnológicas: contribuições para compreender as reestruturações produtivas do setor Saúde. Interface, Botucatu, v. 4, n. 6, p.109-116, 2000. DOI: 10.1590/S1414-32832000000100009
https://doi.org/10.1590/S1414-3283200000... ) argues that there is a set of soft-hard technologies that cuts across the use of soft and hard technologies: structured knowledge. At the very least, it is necessary to master anatomical repertoires, to know the mechanisms of labor and the physiology of this event in order to implement practices that use the body in favor of childbirth, as we have seen these professionals do.

I know . What is this knowledge? In the optimal fifth term, the course’s curricular structure provides that, provided they have fulfilled the prerequisites, students take Physiology of Pregnancy, Childbirth and Postpartum, covering pregnancy adaptations in systems studied previously. In addition, this subject introduces content that will be mobilized directly in clinical practice by midwives, such as the physiology and determinism of childbirth, as well as its clinical periods.

According to the course’s political pedagogical project (EACH, ²⁰¹⁷ EACH – ESCOLA DE ARTES, CIÊNCIAS E HUMANIDADES DA UNIVERSIDADE DE SÃO PAULO. Projeto político pedagógico curso de graduação em obstetrícia. São Paulo, 2017. Disponível em: http://www5.each.usp.br/wp-content/uploads/2015/11/PPP-Obstetr%C3%ADcia-2017.pdf . Acesso em: 3 out. 2023.
http://www5.each.usp.br/wp-content/uploa... ), these subjects lay the foundations for specific knowledge about pregnancy, childbirth, and the postpartum period, awakening scientific and critical thinking by proposing an active and cooperative learning process. Following the recommendations and guidelines of the ICM on the model of care that should be offered by midwives, it is imperative that the promotion of critical and scientific reasoning is present in the basic disciplines, extending to those that prepare professionals for clinical practice. According to the ICM, the ethical and competent care provided by midwives should always be guided by formal and continuing education, scientific research, and the practical application of evidence (ICM, ²⁰¹⁴ ICM – International Confederation of Midwives. Philosophy and modelo of Midwifery care, 2014. Disponível em: https://www.internationalmidwives.org/assets/files/general-files/2020/07/cd0005_v201406_en_philosophy-and-model-of-midwifery-care.pdf. Acesso em: 13 set. 2023.
https://www.internationalmidwives.org/as... ).

Mirroring the political pedagocial project (PPP) of the Midwifery course, our interviewees place scientific evidence as one of the main points of support and legitimization for their daily childbirth care practices. The proposal for care based on scientific evidence is put forward as the principle that guides the practice of this professional category.

Although scientific evidence guides the work of these professionals, midwives make it clear that home birth care has its own specificities. For example, it is not the average duration of the process, calculated on the basis of a large sample, that will determine how long a labor can last without the need for more resolute interventions. At home, it relies on careful monitoring to assess whether there is a need to use any measures or, on the contrary, to assess whether the situation can be ‘carried on’ for a while longer:

In this sense, midwives are sensitive to what Canguilhem ( ²⁰⁰⁹CANGUILHEM, G. O normal e o patológico. 6. ed. Rio de Janeiro: Forense Universitária, 2009. ) called the individual relativity of the normal, a principle according to which the normal cannot be trapped in the average, nor reduced to what is most common in a population. In other words, normal childbirth is not necessarily the average childbirth. Therefore, despite their undeniable importance, scientific productions of a quantitative nature are not the only type of legitimate knowledge to guide the entire process of decision-making and action in the daily lives of midwives.

In order to deal properly with the bodies that, when giving birth, call this statistical normativity into question, it is necessary that sensitive knowledge is no longer understood as a source of deception but as valid within the production of knowledge. Those who practice the art of midwifery must not only observe, but also feel and listen to those they encounter, turning to the parturient body in search of uniqueness—apprehensible through easily overlooked details—that can guide care and action in the face of possible complications and even the conscious use of scientific evidence.

In this sense, monitoring vital signs is a great ally for professionals in detecting real risk and, consequently, using interventions to manage this risk and avoid negative outcomes. Detecting them, however, requires dedication and keen senses (Mortelaro; Cirelli, ²⁰²¹MORTELARO, P. K.; CIRELLI, J. F. Corpos em relação: contribuição das epistemologias feministas para uma prática obstétrica situada. Saúde em debate, n. 45, v. esp. 1, p. 168-180, 2021. DOI: 10.1590/0103-11042021E113
https://doi.org/10.1590/0103-11042021E11... ).

Another key aspect is the way in which midwives’ work is based on experience. In this sense, it is pointed out that many elements go into the decision to use conducts in labor or to intervene in a certain way, but when it comes to the knowledge involved in the process, the experience is just as important as scientific evidence.

Experience is constantly mentioned as one of the central aspects of training as a midwife. In addition to the experience acquired during their own professional practice, the knowledge acquired by midwives is also closely linked to the experience of other certified midwives.

Finally, there is a fundamental aspect to the practice of these professionals that escapes the linear forms of inductive and deductive reasoning that are granted the monopoly of legitimacy in relation to knowledge production in Western societies (Davis, ¹⁹⁸⁹DAVIS, E. Women’s intuition. Berkeley: Celestial Arts, 1989. ). It consists of intuition as a source of knowledge underpinning the decision-making process and actions of midwives.

In this sense, it is argued that, besides all the knowledge provided by the medical tradition and which underpins their training, midwives depend on their intuition to act appropriately, or, in their words, on what they call the midwife’s sense.

This sense refers to a very specific way of thinking that is more akin to a flow of impressions, a variety of elements that professionals connect almost automatically, so that they can act intuitively in labor.

Intuition presents itself as a way of relating to the knowledge that these professionals have learned, in a fragmented way, about labor, an event which, despite our efforts to simplify it, remains complex. Although the training of our interviewees is still situated within a biomedical model—despite constant efforts to reform it, shifting it from the technocratic paradigm to the humanized paradigm—they have developed the ability to reconnect broken links, bringing together scientific evidence, knowledge produced about the physiology and anatomy of the female and parturient body, clinical signs and other unique elements that relate to each parturition experience.

Final considerations

At first glance, the professionals’ work is in line with the recommendations of the World Health Organization, implementing care aimed at keeping the mother and baby healthy and safe, using as few interventions as possible, always in keeping with safety. To this end, they use the technologies in their toolbox, in accordance with professional regulations, be they soft or hard, employing them through careful observation of the process and interpretation of the findings.

In these professionals’ toolbox we can find everything from soft, relational technologies to hard, material technologies. The latter include both the instruments produced by human activity—stool, amniotome, needle and thread for suturing—and the very bodies of midwives and parturient women. We were able to identify that professionals resort to hard technologies when they are unable to achieve the desired end with relational technologies, although they use the latter throughout the process.

In order to use these technological resources, professionals draw on very different types of knowledge, without necessarily ranking them. These include the disciplines that structure university education, scientific evidence, and sensitive knowledge, which come together to form a tripod that supports decision-making. In order to combine such different—and sometimes contradictory—sources of knowledge, intuition seems to play a fundamental role, enabling the knowledge they carry with them to be effectively put into relation when assisting each specific parturition experience. Finally, the experience they acquire through years of practice and with other more experienced midwives allows them to develop the ability to handle and use everything they have at their disposal in an increasingly appropriate and assertive way.

In short, the aspects of attention to PHB discussed and analyzed here are an initial approach to the subject. Although the small number of participants allowed important aspects of the use of technologies to be addressed in depth, the selection of participants by indication and the geographical restriction are limitations of this study. In addition, the restriction to midwives as research subjects may contribute to overlooking PHB care practices employed by urban midwives with other training paths, such as nurse midwives, and who work in other regions of Brazil, if such specificities exist. For this reason, further research is needed to expand the production of knowledge about the technological toolbox of urban midwives and the criteria adopted for mobilizing and using these tools.

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