WHEN TO GO TO THE HOSPITAL MATERNITY ? HEALTH EDUCATION IN LABOR

Objective: to report the academic experience in promoting health education about warning signs and labor for pregnant women. Method: a qualitative, descriptive study, a type of experience report, in which 15 students were trained to form the group, in which they were discussed: warning signs, false and true labor and didactic strategies for approaching pregnant women, supported by articles and guidelines. Three academics interviewed 100 pregnant women with their own instrument containing ten questions. After the training and the collection, the group prepared an educational material that was evaluated and, after adjustments, folders were made. Results: only 21% of pregnant women received guidance on the subject. After responding to the questionnaire, all the women received guidance (n = 100) and 196 were collectively oriented through the waiting room and folder distribution strategies. Conclusion: there was a need for Health Education for pregnant women; indissociability between teaching-research-extension and the need to produce community-oriented knowledge on the subject. Descriptors: Parturition; Labor, Obstetric; Health Education. RESUMO Objetivo: relatar a experiência acadêmica em promover educação em saúde sobre sinais de alerta e de trabalho de parto para gestantes. Método: estudo qualitativo, descritivo, tipo relato de experiência, em que foram capacitados 15 acadêmicos para compor o grupo, no qual foram discutidos: sinais de alerta, falso e verdadeiro trabalho de parto e estratégias didáticas para a abordagem de gestantes, respaldados em artigos e diretrizes. Três acadêmicas entrevistaram 100 gestantes com instrumento próprio contendo dez questões. Após a capacitação e a coleta, o grupo elaborou um material educativo que foi avaliado e, após ajustes, foram confeccionados folders. Resultados: apenas 21% das gestantes receberam orientações sobre o tema. Após responder ao questionário, todas as mulheres receberam orientações (n=100) e 196 foram orientadas coletivamente por meio das estratégias sala de espera e distribuição de folder. Conclusão: verificou-se a necessidade de Educação em Saúde para as gestantes; indissociabilidade entre ensino-pesquisa-extensão e necessidade da produção de conhecimentos voltados para a comunidade sobre o tema. Descritores: Parto; Trabalho de Parto; Educação em Saúde. RESUMEN Objetivo: relatar la experiencia académica en promover educación en salud sobre señales de alerta y de trabajo de parto para gestantes. Método: estudio cualitativo, descriptivo, tipo relato de experiencia, en que fueron capacitados 15 académicos para componer el grupo, en el cual fueron discutidos: signos de alerta, falso y verdadero trabajo de parto y estrategias didácticas para el abordaje de gestantes, respaldados en artículos y directrices. Tres académicas entrevistaron a 100 gestantes con instrumento propio conteniendo diez cuestiones. Después de la capacitación y la colecta, el grupo elaboró un material educativo que fue evaluado y después de ajustes fueron confeccionados folders. Resultados: solo 21% das gestantes recibieron orientaciones sobre el tema. Después de responder el cuestionario, todas las mujeres recibieron orientaciones (n=100) y 196 fueron orientadas colectivamente a través de las estrategias: sala de espera y distribución de folder. Conclusión: se verificó la necesidad de Educación en Salud para las gestantes; disociación entre enseñanza-investigación-extensión y necesidad de la producción de conocimientos dirigidos a la comunidad sobre el tema. Descriptores: Parto; Trabajo de Parto; Educación en Salud. Academics of the Undergraduate Nursing Course, Federal University of Triângulo Mineiro / UFTM. Uberaba (MG), Brazil. E-mails: thais_gabriela_15@hotmail.com; hevyllin_rodrigues@hotmail.com; carolina.c.camargos@hotmail.com; Nurse, PhD, Professor, Undergraduate Nursing Course, Federal University of Triângulo Mineiro (UFTM), Uberaba (MG), Brazil. E-mail: anarita@mednet.com.br; Obstetrician, PhD, Professor, Medicine Undergraduate Course, Federal University of Triângulo Mineiro / UFTM. Uberaba (MG), Brazil. Email: marinacp@terra.com.br; Obstetric Nurse, PhD, Professor, Undergraduate Nursing Course, Federal University of Triângulo Mineiro / UFTM. Uberaba (MG), Brazil. E-mail: marianatorreglosa@hotmail.com CASE REPORT ARTICLE Matias TGC, Félix HCR, Corrêa CC et al. When to go to the hospital maternity?...

English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5478-84, Dec., 2017 5479 Health education is an important tool in assisting the pregnancy-puerperal cycle, since pregnancy is a delicate period and generates potential doubts and anxiety for the future mother, father and relatives of both. 1 In a study of social representations, the pregnant women represented educational actions through speech: "I thought I knew, but did not know", indicating the importance of such activities.According to the same study, women represented the term health education by the words "education", "information", "learning" and "knowledge".When questioned about the importance of the activity, they used the terms "health", "respect", "improve" and "attention".The educational practices were represented by the words "lectures", "family and school education" and "media" . 1 Health education, as a practice during prenatal care, can be represented in several ways, with lectures, groups of pregnant women and individual educational actions during consultations being more common.According to researchers, the lectures can be defined as an exposition of a theme, which can be dialogued or not, depending on who speaks it.The groups of pregnant women represent good pedagogical strategies of socialization of knowledge and construction of group knowledge and should be stimulated as an educational practice among nurses.The moment of the consultation would be the legitimate space, chosen and ideal for individualized educational actions.However, educational actions should not be restricted only at this time, since the prenatal consultation involves many activities, such as: assistance activities, physical examination, managerial activities, filling of forms and prenatal card, and, know the number of appointments scheduled for professionals, which could reduce or abolish this activity during the consultation. 1t least, during prenatal care, the waiting room becomes a potential space for health education.It is a dynamic space where, while waiting for the consultation, the idle time is filled with information of interest for the health of the pregnant woman and the newborn, for the same and all who are accompanying. 2 should also be noted that, in this educational process, the involvement and participation of family members is very important, since the pregnant woman can be divided between 'what the professional says' and 'what the family says'.In this way, family members should be invited and encouraged to participate in this process, since knowledge can not be restricted only to passing on information, but should consider individual aspects such as culture, experiences, fears, doubts, beliefs and expectations of the pregnant woman and whole family. 3ong the topics that should be addressed during health education for pregnant women, are the orientation of signs and symptoms of childbirth and warning signs, that is, indicative signs for the pregnant woman to seek the reference maternity for evaluation.Warning signs include: vaginal bleeding, headache, visual changes, abdominal pain, fever, vaginal losses, respiratory distress, among others. 4 addition to these signs and symptoms, women should be encouraged to look for motherhood whenever they are worried or afraid, as they are able to recognize any important changes to their bodies and this factor complements professional knowledge. 5e woman should, also, be guided about signs and symptoms of labor that can be defined as: the presence of regular uterine contractions that progressively increase in frequency and intensity, which do not diminish or cease with rest, often every three to five minutes and duration ranging from 20 to 60 seconds, associated with the dilation and dilation of the uterine cervix, which should be evaluated by a health professional.It is emphasized that the loss of the mucous plug is a premonitory signal, but, it is not indicative of labor, as well as rupture of amniotic membranes, which occur before labor in 12 to 20% of cases. 6e orientation of the warning signs and labor during prenatal care aims to reduce the length of hospital stay of parturients, once it is admitted to labor in the active phase. 6In addition to reducing hospitalization time, hospitalization in the active phase, in real labor, reduces the risk of errors in the identification of dystocia, unnecessary interventions and operative births. 6 should be emphasized that it is incumbent upon midwifery health professionals to know the signs indicative of the onset of labor and its physiology, and they should teach women and their families about warning signs and labor and when to seek referral maternity. 7 is observed that there are few studies, in the literature, that address the thematic and the evaluation of the knowledge of the subject by pregnant women, as well as factors

INTRODUCTION
English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5478-84, Dec., 2017 5480 that influence the recognition of these signs.Thus, the study on the knowledge about warning signs and labor during pregnancy may indicate the need to carry out educational activities in the institution where the data were collected, as well as other institutions that provide prenatal care, justifying the need for research and extension projects on the subject.
• To report the academic experience in promoting health education about warning signs and labor for pregnant women.
A qualitative, descriptive study of the type of experience report, constructed from the systematic observation of a lived reality.It was developed, from experiences of Health Education, the research project and extension entitled "When to go to the maternity?Guidelines on warning signs and labor ", carried out within the framework of the Federal University of the Triângulo Mineiro, in the period from March 1 st to November 31, 2016.

• Related experience
The Health Education activities were carried out in an outpatient clinic of a teaching hospital, which is a reference for the high-risk prenatal care of the city of Uberaba (MG) and region, composed of 27 municipalities, and for gestation of habitual risk of residents of District I of the municipality (population estimated at 150 thousand inhabitants).
Fifteen students of the Nursing course were selected to form the group that developed the educational activities, through interviews and analysis of the academic background of the students.During the training for the development of the project, the following themes were discussed: warning signs, false and true labor and didactic strategies for approaching pregnant women based on scientific articles and guidelines of the World Health Organization (WHO) and the Ministry of Health (MH), with a duration of 40 hours.
Meanwhile, three academics interviewed 100 pregnant women on the subject, according to the previous sample calculation, in order to determine the prior knowledge and the need for Health Education on the subject.Pregnant women were interviewed from the 30th gestational week, regardless of age, and those under the age of 18 years were authorized by the legal guardians and assented to their consent.Pregnant women with incomplete fetal malformations (detected by medical evaluation and diagnoses), cognitive deficits, and / or who had, as an outcome, abortion, stillbirth or stillbirth, were excluded from the study.
A total of 100 pregnant women were included in the study.In order to determine the sample size, the PASS (Power Analysis and Sample Size), 2002 version, was used, where the following values and information were introduced: an a priori determination coefficient R² = 0.13 was considered in one linear regression model, with significance level α = 0.05.A sample size (n) was obtained with at least 99 subjects.The dependent variable was the knowledge score of pregnant women regarding warning signs and labor.
The pregnant women were approached by the academics in the waiting room or after the prenatal visit, oriented on the objectives of the study and invited to participate according to the inclusion and exclusion criteria established.The data collection took place in a clinic provided by the institution, respecting the principles of secrecy and privacy.
Sociodemographic data, health conditions, previous and current obstetric history were collected through interviews or records in medical records.The instrument of data collection was constructed by the authors themselves.Prior to the collection, a pilot study was carried out with ten pregnant women and the instruments collected in the pilot were excluded from the analysis.There was no inclusion or exclusion of variables after the pilot test, since all were adequate to respond to the objectives of the study.
Regarding the knowledge about warning signs and labor, the pregnant women answered ten questions, with four alternatives of answers, and only one correct answer should be pointed out.
Participants' knowledge was measured by their total success.Regarding the objective that corresponds to previous knowledge / guidelines, these were considered when the pregnant woman reported that she participated in a group of pregnant women, received individual counseling during consultations, participated in lectures or waiting rooms during pregnancy.The pregnant women could respond to the researchers or from their own handwriting.
The issues addressed the following topics: 1 -Premonitory signs of labor; 2 -loss and mucosal cap characteristics; 3 -how to identify rupture of amniotic membranes; 4 -  4 During the collection and analysis of the data, the preparation of illustrated educational material (folder) and the standardization of the waiting room were carried out simultaneously in a period of one month (weekly meetings), with a workload of 40 hours for these activities.The illustrations of the didactic material were carried out by an academic belonging to the group and then were digitized and made into an archive for printing.

METHOD
The educational material was submitted to 26 judges for adjustments, composed of four professors (of Medicine and Nursing courses), ten physicians residing in Gynecology and Obstetrics, ten pregnant women, one nurse assistant and one social worker.After the textual adaptations, according to the judges' suggestion, the material was printed for distribution.
The folder, in its final version, presented the following themes: 1 -Warning signs -you should seek maternity if ...; 2 -What to take to the maternity ?; 3 -Guidelines for the accompanying person; 4 -How to detect uterine contractions; 5 -Characteristics of the bag rupture and what to do; 6 -Tips for breastfeeding; 7 -To know if the baby is packed, be aware of these signs (signs of labor); 8 -Characteristics of the mucous plug and 9 -Signs that precede the labor.
After the preparation of the material, the students, divided into trios, performed educational activities, weekly, on Tuesdays and Thursdays in the afternoon, with pregnant women assisted in the outpatient clinic, for a period of two months (September and October 2016).

Results
The mean age of pregnant women interviewed was 28.2 ± 7.0 years, ranging from 14 to 45 years.Of these, 5% were adolescents and 18% were 35 years of age or older.The majority resided in the municipality of Uberaba (69%), claimed to be married (85%), had no paid activity (60%) and had no income of their own (61%).Regarding the self-reported color, 40% declared themselves to be brown; 28%, white and 26% black, and, in terms of schooling, women with incomplete elementary education (27%) and complete secondary education (27%) were more frequent in the sample.
Regarding the obstetric data, the mean gestational age at the time of the interview was 34.7 ± 3.1, ranging from 30 to 40 weeks of gestation.The mean number of pregnancies found was 2.9 ± 1.8, ranging from one to ten pregnancies, with a predominance of secondary pregnancies in the sample (28%); the mean number of antenatal visits performed was 7.4 ± 2.7 visits, ranging from one to 16 consultations.The mean number of live children was 1.5 ± 1.6, ranging from zero to seven children per pregnant woman and 35% of pregnant women had experience of previous abortion.
When asked if they participated in a group of pregnant women in their communities, only 21% reported participation, and when questioned about professional guidelines on warning signs and labor during prenatal care, 61% reported not having received any type of information.
Concerning the questions regarding the knowledge about the warning signs and of labor, ten questions related to the topic were made.In the identification of signs that precede labor, 68% could not identify what these signs are; 63% had information about the loss of mucus plug as a premonitory signal rather than labor; 63% of the pregnant women did not recognize the signs of rupture of the pouch (amniocoronic membranes); 72% were unaware of the characteristics of the amniotic fluid, and 68% did not know what to do if the bag ruptured, demonstrating a large gap in the information / knowledge about the rupture of the bag; 90% acknowledged that bleeding is a warning sign and should be promptly evaluated by the health team; 58% were oriented to recognize uterine dynamics and signs of labor, but 65% did not identify factors that interfere in contraction, generating false labor; 68% were unable to report normal or impaired fetal movement, and 87% were able to distinguish symptoms of complications that need to be assessed during pregnancy (Table 1 All the interviewed women (n = 100), after responding to the form, were instructed on the warning and labor signals by the project's students.
As for the Health Education activities, carried out collectively, 196 pregnant women participated in the waiting room activities, all of which received the educational material made by the group (Figure 1).
So that in all, 296 pregnant women benefited, from the project.It is noteworthy that 2000 folders were printed, which continue to be delivered to the institution, even after project closure.
English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5478-84, Dec., 2017 5483 The results obtained in the project were in agreement with the literature data, since all the women were undergoing prenatal care, however, only 21% participated in a guidance group of pregnant women, and 61% reported not receiving any type of information on warning signs and labor.In a study that evaluated prenatal care in a Brazilian municipality, it was found that 98% of the pregnant women performed at least one prenatal visit; 90% performed more than six consultations (as recommended by the Ministry of Health); 40% of these women performed six or more consultations, started prenatal care in the first trimester, performed all basic laboratory tests and had tetanus coverage.However, when analyzing the frequency of educational activities, it was observed that only 11% of the pregnant women participated in some educational action during pregnancy, receiving the lowest frequency score among all evaluated items. 8 is also worth noting that qualitative research has indicated that some pregnant women arrived at maternity without receiving any information during the prenatal period regarding labor. 9In this way, the results of the project point to the need for Health Education and better care prenatal.
It was concluded, from the interviews, that most of the pregnant women did not receive guidance on the warning signs and labor during prenatal care, with reflection on the answers regarding the subject studied.There was a greater delay in recognizing premonitory signs; identify and proceed with regard to the broken bag; to identify changes in fetal movement and uterine contractions.However, they recognize the need for evaluation when faced with bleeding and are able to identify potential complications.
From the results, the need for Health Education on warning signs and labor for the target public was verified.Health Education during pregnancy is a strategy of prevention and health promotion for the mother and the baby and aims to minimize or even eradicate future disorders.The forms of representation of this education can be of several ways like: lectures, groups of pregnant women and educational actions, being able to occur collectively (waiting room) or individual (office).In addition, the distribution of educational material, with clear, accessible and illustrated language, can facilitate the learning of content, since the woman can read at home, as often and at what time as she wants.
The project carried out can prove the indissociability between teaching-researchextension and its relevance to academic training and the need to produce knowledge CONCLUSION DISCUSSION

Figure 1 .
Figure 1.Layout of educational material: When to go to the maternity?Signs of Alerting and Signs of Labor, Uberaba, MG, 2016.

Table 1 .
). Frequency of the variables on the knowledge of the warning signs and work and birth of the 100 pregnant women interviewed.