Classification of deaths in women with human immunodeficiency virus/acquired immunodeficiency syndrome in pregnancy and childbirth. / Classificação de óbitos em mulheres com vírus da imunodeficiência humana/síndrome da imunodeficiência adquirida no ciclo gravídico-puerperal.

OBJECTIVE: To reclassify deaths of women infected with the human immunodeficiency virus/acquired immunodeficiency syndrome in pregnancy and childbirth in the State of Pernambuco, Brazil, from 2000 to 2010. METHODS: A descriptive exploratory study, developed from the following steps: translation to Portuguese of the item "HIV and aids" of the United Nations document "The WHO application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: DCI MM 2012"; development of a classification algorithm of deaths of women living with the human immunodeficiency virus/acquired immunodeficiency syndrome in pregnancy and childbirth; and reclassification of deaths by a group of experts. RESULTS: Among the 25 reclassified deaths, 12 were due to human immunodeficiency virus/acquired immunodeficiency syndrome, and pregnancy condition was coexisting; 9 were reclassified as indirect maternal death, with O98.7 code, proposed by the World Health Organization; 2 as direct/indirect maternal death; and 2 were considered indeterminate. CONCLUSION: The reclassification showed a possible pattern of change in maternal mortality, since most of the deaths were attributed to the virus and may lead to a reduction in deaths from maternal causes. The algorithm will subsidize the use of the new classification of maternal death and human immunodeficiency virus/acquired immunodeficiency syndrome.

OBJETIVO: Reclassificar os óbitos de mulheres portadoras do vírus da imunodeficiência humana/síndrome da imunodeficiência adquirida no ciclo gravídico-puerperal no Estado de Pernambuco, no período de 2000 a 2010. MÉTODOS: Estudo descritivo exploratório, desenvolvido a partir das seguintes etapas: tradução para português do item "HIV and aids" do documento da Organização das Nações Unidas "The WHO application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM, 2012"; elaboração de um algoritmo de classificação dos óbitos de mulheres portadoras do vírus da imunodeficiência humana/síndrome da imunodeficiência adquirida no ciclo gravídico-puerperal; e reclassificação dos óbitos por um grupo de especialistas. RESULTADOS: Dentre os 25 óbitos reclassificados, 12 foram devido ao vírus da imunodeficiência humana/síndrome da imunodeficiência adquirida e a condição gravídica era coexistente; 9 foram reclassificados como morte materna obstétrica indireta, com o código O98.7, proposto pela Organização Mundial de Saúde; 2 como morte materna obstétrica direta/indireta; e 2 foram considerados indeterminados. CONCLUSÃO: A reclassificação apontou uma possível mudança de padrão de mortalidade materna, visto que a maioria dos óbitos foi atribuído ao vírus, podendo levar a uma redução dos óbitos por causas maternas. O algoritmo subsidiará o uso da nova classificação sobre morte materna e do vírus da imunodeficiência humana/síndrome da imunodeficiência adquirida.

Classificação de óbitos em mulheres com vírus da imunodeficiência humana/síndrome da imunodeficiência adquirida no ciclo gravídico-puerperal / Classification of deaths in women with human immunodeficiency virus/acquired immunodeficiency syndrome in pregnancy and childbirth

RESUMO: Objetivo: Reclassificar os óbitos de mulheres portadoras do vírus da imunodeficiência humana/síndrome da imunodeficiência adquirida no ciclo gravídico-puerperal no Estado de Pernambuco, no período de 2000 a 2010. Métodos: Estudo descritivo exploratório, desenvolvido a partir das seguintes etapas: tradução para português do item "HIV and aids" do documento da Organização das Nações Unidas "The WHO application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM, 2012"; elaboração de um algoritmo de classificação dos óbitos de mulheres portadoras do vírus da imunodeficiência humana/síndrome da imunodeficiência adquirida no ciclo gravídico-puerperal; e reclassificação dos óbitos por um grupo de especialistas. Resultados: Dentre os 25 óbitos reclassificados, 12 foram devido ao vírus da imunodeficiência humana/síndrome da imunodeficiência adquirida e a condição gravídica era coexistente; 9 foram reclassificados como morte materna obstétrica indireta, com o código O98.7, proposto pela Organização Mundial de Saúde; 2 como morte materna obstétrica direta/indireta; e 2 foram considerados indeterminados. Conclusão: A reclassificação apontou uma possível mudança de padrão de mortalidade materna, visto que a maioria dos óbitos foi atribuído ao vírus, podendo levar a uma redução dos óbitos por causas maternas. O algoritmo subsidiará o uso da nova classificação sobre morte materna e do vírus da imunodeficiência humana/síndrome da imunodeficiência adquirida.

ABSTRACT: Objective: To reclassify deaths of women infected with the human immunodeficiency virus/acquired immunodeficiency syndrome in pregnancy and childbirth in the State of Pernambuco, Brazil, from 2000 to 2010. Methods: A descriptive exploratory study, developed from the following steps: translation to Portuguese of the item "HIV and aids" of the United Nations document "The WHO application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: DCI MM 2012"; development of a classification algorithm of deaths of women living with the human immunodeficiency virus/acquired immunodeficiency syndrome in pregnancy and childbirth; and reclassification of deaths by a group of experts. Results: Among the 25 reclassified deaths, 12 were due to human immunodeficiency virus/acquired immunodeficiency syndrome, and pregnancy condition was coexisting; 9 were reclassified as indirect maternal death, with O98.7 code, proposed by the World Health Organization; 2 as direct/indirect maternal death; and 2 were considered indeterminate. Conclusion: The reclassification showed a possible pattern of change in maternal mortality, since most of the deaths were attributed to the virus and may lead to a reduction in deaths from maternal causes. The algorithm will subsidize the use of the new classification of maternal death and human immunodeficiency virus/acquired immunodeficiency syndrome.

The effect of waterbirth on neonatal mortality and morbidity: a systematic review and meta-analysis.

BACKGROUND: Women have been giving birth in water in many centers across the globe; however, the practice remains controversial. Qualitative studies highlight the benefits that waterbirth confers on the laboring woman, though due to the nature of the intervention, it is not surprising that there are few randomized controlled trials available to inform practice. Much of the criticism directed at waterbirth focuses on the potential impact on the neonate. OBJECTIVES: The objective of this review was to systematically synthesize the best available evidence regarding the effect of waterbirth, compared to landbirth, on the mortality and morbidity of neonates born to low risk women. INCLUSION CRITERIA: This review considered studies that included low risk, well, pregnant women who labor and birth spontaneously, at term (37-42 weeks), with a single baby in a cephalic presentation. Low risk pregnancies are defined as pregnancies with an absence of co-morbidity or obstetric complication, such as maternal diabetes, previous cesarean section, high blood pressure or other illness. Women may be experiencing their first or subsequent pregnancy. The fetus must also be well and without any co-morbidity or complication.The intervention of interest is waterbirth. The comparator is landbirth. Women and their babies must be cared for by qualified maternity healthcare providers throughout their labor and birth. The birth setting must be clearly described but can include home, hospital or birth center, either freestanding or attached to a hospital.This review considered randomized controlled trials, quasi-experimental studies and observational prospective and retrospective cohort studies. SEARCH STRATEGY: A multi-step search strategy was utilized to find published and unpublished studies, in English between January 1999 and June 2014. METHODOLOGICAL QUALITY: The first author assessed the quality of all eligible studies. The three secondary authors independently assessed six studies each, followed by group discussion using the appropriate Joanna Briggs Institute appraisal checklist. DATA EXTRACTION: Data were extracted using a standardized extraction tool from Joanna Briggs Institute. DATA SYNTHESIS: Quantitative studies were pooled, where possible, for meta-analysis using software provided by Cochrane. Effect sizes were expressed as odds ratio or relative risk, according to study design, and the 95% confidence intervals were calculated. Heterogeneity was assessed statistically using the standard Chi-square test. RESULTS: The meta-analyses of 12 studies showed that for the majority of outcomes measured in this review there is little difference between waterbirth and landbirth groups. Meta-analysis was not conducted for mortality within 24 days of birth. Heterogeneity was significant between studies for APGAR (Appearance, Pulse, Grimace, Activity, and Respiration). scores ≤7 at one minute and admission to Special Care nursery. Sensitivity analysis for case control studies describing infection found results that were not statistically significant (OR 0.74, 95% CI 0.05-11.06). Results of meta-analysis were also not significant for studies describing resuscitation with oxygen (OR 1.12, 95% CI 0.14-8.79) and Respiratory Distress Syndrome (OR 0.81, 95% CI 0.44-1.49). Results comparing APGAR scores ≤7 at five minutes for waterbirth and landbirth groups results for included RCTs demonstrated results that were not statistically significant (OR 6.4, 95% CI 0.63-64.71). However, results for included cohort studies describing APGAR scores ≤7 at 5 minutes indicate neonates are less likely to have scores ≤7 in the waterbirth group (OR 0.32, 95% 0.15-0.68). Data were not statistically significant for meta-analysis describing admission to NICU (OR 0.51, 95% CI 0.13-1.96) between water and landbirth groups. The differences in arterial (MD 0.02, 95% CI 0.01-0.02) and venous (MD 0.03, 95% CI 0.03-0.03) cord pH, while statistically significant, were clinically negligible. CONCLUSIONS: Analyses of data reporting on a variety of neonatal clinical outcomes comparing land with waterbirth do not suggest that outcomes are worse for babies born following waterbirth. Meta-analysis of results for five-minute APGAR scores ≤7 should be treated with caution due to the different direction of results for meta-analysis of data from randomized controlled trials and cohort studies. Data measuring cord pH (an objective measure of neonatal wellbeing) were robust and showed no difference between groups. Overall this review was limited by heterogeneity between studies and meta-analysis could not be conducted on a number of outcomes. Waterbirth does not appear to be associated with adverse outcomes for the neonate in a population of low risk women. IMPLICATIONS FOR PRACTICE: There is no evidence to suggest that the practice of waterbirth in a low risk population is harmful to the neonate. IMPLICATIONS FOR RESEARCH: There is a paucity of high level evidence to guide practice in the area of waterbirth. It is unlikely that randomized controlled trials on waterbirth will be acceptable to childbearing women or maternity caregivers. Observational studies are a more appropriate choice for researchers in this field as they offer a more practical and ethical approach.

A Population-based study on trends in the mode of delivery subsequent to stillbirth, infant mortality and severe infant malformations in the state of Hesse, Germany between 1990 and 2012.

BACKGROUND: Women giving birth to a child with severe infant malformations or suffering a stillbirth certainly experience a mental trauma. Therefore the objective of the present study is to examine the incidence of deliveries subsequent to such a traumatic experience as well as the mode of delivery. Secondly, the results are compared to the changes of a non-affected group of deliveries over the last 23 years in the state of Hesse, Germany. METHODS: The total obstetric dataset of the Hessian Perinatal Registry (HEPE) was assessed for women with regard to one item of the pregnancy risk factors. This particular HEPE item comprises information on the rates of stillbirth, early and late infant mortality (≤7 days,<1 year) as well as severe infantile malformations in women giving birth subsequent to such an extensive traumatic experience. The identified women were categorized with respect to the mode of delivery (spontaneous, vaginal operative or Cesarean section), pre- and full-term birth and according to 4 time-frames between 1990 and 2012. The results of women with a positive HEPE item were compared to those of women without such a traumatic experience (non-affected group) of the HEPE analyzed in the same categories and time-frames. RESULTS: The obstetric dataset from 1990 until 2012 of the HEPE comprised altogether 1 224 760 deliveries including a group of 19 726 (1.61%) deliveries subsequent to a positive result for the analyzed HEPE item. Over the duration of follow-up the rate of subsequent pregnancies following such a traumatic experience showed a significantly decrease of 43% in comparison to the previous time-frame, respectively (1990-1996: 30.3%; 2008-2013: 17%; P≤0.0001). With respect to the mode of delivery (spontaneous, vaginal operative, Cesarean section) the results in the group subsequent to the positive HEPE item (1 862, 55.5%; 70, 2.1%; 1 416, 42.2%) were significantly different (P<0.001) in comparison to the non-affected group (142 846, 59.9%; 13 875, 5.8%; 81 089, 34.0%), respectively. DISCUSSION: Rising rates of CSs and conversely decreased numbers of vaginal deliveries in most cases of full-term pregnancies contrast with the reduction of the positive HEPE item over the last 23 years. There seems to be an urgent need for action since this observed critical trend remains highly significant in comparison with the rising trend of CS in general. Pre-pregnancy counseling and continuous monitoring during pregnancy and delivery in consciousness of evident risk factors may be an opportunity to cope with these serious findings.

Change in primary midwife-led care in the Netherlands in 2000-2008: a descriptive study of caesarean sections and other interventions among 789,795 low risk births.

OBJECTIVE: to study whether an increase in intrapartum referrals in primary midwife-led care births in the Netherlands is accompanied by an increase in caesarean sections. DESIGN: nationwide descriptive study. SETTING: the Netherlands Perinatal Registry. PARTICIPANTS: 789,795 births of nine year cohorts of women with low risk pregnancies in primary midwife-led care at the onset of labour between 2000 and 2008. MEASUREMENTS: primary outcome is the caesarean section rate. Vaginal instrumental delivery, augmentation with oxytocin, and pharmacological pain relief are secondary outcomes. Trends in outcomes are described. We used logistic regression to explore whether changes in the planned place of birth and other maternal characteristics influenced the caesarean section rate. FINDINGS: the caesarean section rate did not increase and was 5.5 per cent (range 4.9-6.3 per cent) for nulliparous women, and 1.0 per cent (range 0.8-1.1 per cent) for multiparous women. After controlling for the decline in planned home births and other maternal characteristics no increase in the caesarean section rate was found. The vaginal instrumental birth rate showed no increase, and was 18.1 per cent (range 17.9-18.5 per cent) for nulliparous women and 1.5 per cent (range 1.4-1.7 per cent) for multiparous women. Augmentation of labour and/or pharmacological pain relief increased from 24.0 to 38.8 per cent for nulliparous women, and from 5.4 to 10.0 per cent for multiparous women. CONCLUSION: the rise in intrapartum referrals was not accompanied by an increase in caesarean section rate over the period 2000-2008. Despite a considerable rise in the use of pain relief and augmentation, the rate of spontaneous vaginal birth remained high for low risk women who started labour in primary midwife-led care. IMPLICATIONS FOR PRACTICE: the current strict role division between primary care midwives and the obstetrician-led team increasingly results in a change in care provider during labour. In a more integrated care system, more women can receive continuous support of labour from their own primary care midwife, as long as only supportive interventions are needed.

Remote midwifery in Nunavik, Québec, Canada: outcomes of perinatal care for the Inuulitsivik health centre, 2000-2007.

BACKGROUND: The Inuulitsivik midwifery service is a community-based, Inuit-led initiative serving the Hudson coast of the Nunavik region of northern Québec. This study of outcomes for the Inuulitsivik birth centers, aims to improve understanding of maternity services in remote communities. METHODS: We used a retrospective review of perinatal outcome data collected at each birth at the Inuulitsivik birth centers to examine outcomes for 1,372 labors and 1,382 babies from 2000 to 2007. Data were incomplete for some indicators, particularly for transfers to Montreal. RESULTS: Findings revealed low rates of intervention with safe outcomes in this young, largely multiparous "all risk" Inuit population. Ninety-seven percent of births were documented as spontaneous vaginal deliveries, and 85 percent of births were attended by midwives. Eighty-six percent of the labors occurred in Nunavik, whereas 13.7 percent occurred outside Nunavik. The preterm birth rate was found to be 10.6 percent. Postpartum hemorrhage was documented in 15.4 percent of women; of these cases, 6.9 percent had blood loss greater than 1,000 mL. Four fetal deaths (2.9 per 1,000) and five neonatal deaths (< 3.6 per 1,000) were documented. Nine percent (9%) of births involved urgent transfers of mother or baby. The most common reasons for medical evacuation were preterm labor and preeclampsia, and preterm birth was the most common reason for urgent neonatal transfer. CONCLUSIONS: The success of the Innulitsivik midwifery service rests on the knowledge and skills of the Inuit midwives, and support of an interprofessional health team. Our study points to the potential for safe, culturally competent local care in remote communities without cesarean section capacity. Our findings support recommendations for integration of midwifery services and Aboriginal midwifery education programs in remote communities.

Maternal outcomes associated with planned vaginal versus planned primary cesarean delivery.

We compared maternal morbidity between planned vaginal and planned cesarean delivery. A university hospital's database was queried for delivery outcomes. Between 1995 and 2005, 26,356 deliveries occurred. Subjects were divided into two groups: planned vaginal and planned cesarean delivery. This was based on intent to deliver vaginally or by cesarean, despite actual route of delivery. Planned vaginal delivery included successful vaginal delivery and labored cesarean delivery intended for vaginal delivery. Planned cesarean delivery included unlabored and labored cesarean delivery and vaginal delivery intended for cesarean. Chart abstraction confirmed the delivery plan. Primary outcomes were chorioamnionitis, postpartum hemorrhage, and transfusion. Secondary outcomes were also measured. A subanalysis compared actual vaginal delivery, labored cesarean delivery, and unlabored cesarean delivery. There were 3868 planned vaginal deliveries and 180 planned cesarean deliveries. Planned cesarean delivery had less chorioamnionitis (2.2% versus 17.2%), postpartum hemorrhage (1.1% versus 6.0%), uterine atony (0.6% versus 6.4%), and prolonged rupture of membranes (2.2% versus 17.5%) but a longer hospital stay (3.2 versus 2.6 days). There were no differences in transfusion rates. For healthy primiparous women, planned cesarean delivery decreases certain morbidities. Labored cesarean delivery had increased risks compared with both vaginal delivery and unlabored cesarean delivery.

[Perinatal outcome of premature infants weighing less than 1500 g]. / Untersuchungen des perinatalen Zustandes bei frühgeborenen Kindern mit weniger als 1500 g.

BACKGROUND: Prematurity is a main issue in modern obstetrical care. The purpose of the present study was to evaluate the perinatal outcome of premature infants weighing less than 1500 g according to the mode of delivery. PATIENTS AND METHODS: 122 patients with infants weighing less than 1500 g were enrolled in this retrospective study (26 to 32 weeks of gestation). The perinatal outcomes of 26 infants born by vaginal delivery were compared to 96 infants delivered by caesarean section. RESULTS: The rates of rupture of membranes, preterm labour and intravenous tocolysis were significantly increased in patients after vaginal delivery. Preeclampsia and pathological cardiotocograms were increased in patients after caesarean section. Infants born by vaginal delivery showed a significant increase of peri- and intraventricular haemorrhage grade III, periventricular leukomalacia, C-reactive protein 24 hours postpartum and mortality until the seventh day of life. However, the rate of bronchopulmonary dysplasia was significantly increased in infants born by caesarean section (p < 0.05). CONCLUSIONS: These data suggest that the mode of delivery affects the perinatal outcome of infants weighing less than 1500 g. Based on the results of the present study, it appears unclear which mode of delivery should be preferred, depending on particular material and fetal factors.

Las lecciones derivadas del ASA Closed Claims Project (ASACCP). Proyecto de la ASA acerca de las razones que promovieron demandas contra anestesiólogos cuyos casos estaban ya archivados (2a parte): La paciente obstétrica. Una actualización / Lessons learned from the ASA Closed Claims Project (ASACCP). ASA Project about the reasons for wich claims against anesthesiologists were rewed in cases that had already been close (part 2): The obstetric patient. An update

El análisis de los últimos casos relacionados con el tema fue publicado en el año 1996 cuando en la base de la ASACCP constaban 3533 demandas terminadas. De éstas, 434 estuvieron relacionadas con la anestesia obstétrica. De las 434 demandas relacionadas con la anestesia obstétrica, 310 correspondieron a la operación cesárea y 124 al parto por vía vaginal con anestesia regional. Las muertes maternas (n=83) y el daño cerebral del recién nacido (n=82) continúan siendo las injurias más frecuentes en las pacientes obtétricas. La muerte materna estuvo más comúnmente relacionada con la anestesia general y con la operación cesárea. A pesar de que el número de muertes maternas consecutivas a la anestesia general se mantuvo estable a través de los años, el número de muertes asociadas a la anestesia regional declinó en forma marcada. Este decremento de muertes maternas bajo anestesia regional ocurrió sobre todo en los años 80, coincidiendo con la prohibición del uso de bupivacaína al 0,75 por ciento. Además, esta declinación se debe, sin duda, a la solución de los problemas creados por la vía aérea, la cual es más difícil de acceder en la mujer embarazada (1:270 en la paciente obstétrica, contra 1:2.230 de la no obstétrica). La necesidad de controlar la vía aérea es crucial para reducir los casos de muerte durante anestesia general. Lo mismo sucede con la anestesia regional cuando la altura del bloqueo es muy elevada o por cualquier otra razón que obligue a convertir una anestesia regional en una general. Siempre existe el temido problema de la aspiración de contenido gástrico, que sigue siendo la primera causa de muerte materna durante la anestesia y casi siempre asociada con una intubación dificultosa o fallida. El daño cerebral del recién nacido se produjo en el 19 por ciento de las demandas estudiadas por la ASACCP. En una Unidad de Cuidados Intensivo de recién nacidos en EE.UU se realizó un estudio retrospectivo, como los estudios de la ASACCP, para analizar el número de demandas relacionadas con los casos internados en dicha unidad. El estudio comprendió el período 1972-1992 durante el cual se produjeron 31 demandas por mala praxis sobre 9367 internaciones, con una incidencia de 0,33 por ciento. Según los autores, la frecuencia de juicios contra los anestesiólogos por problemas vinculados con el recién nacido se incrementó del 0,19 por ciento entre los años 1772-1974 al 0,39 entre 1980 y 1992...

Opcçäo ou imposiçäo! motivos da escolha da cesárea / Option or imposition! reasons of cesarean choice

O parto cesárea no Brasil apresenta uma das taxas mais elevadas do mundo. Estas altas taxas existem por indicações como: preferência da mulher, escolha pelo profissional e como método de esterilização. Segundo VOLOCHKO (1996), estima-se que 28,5 por cento das mortes maternas não ocorreriam se reduzisse as taxas de cesárea. Este estudo surgiu durante o estágio supervisionado na disciplina de Enfermagem Materno Infantil. Buscamos compreender os motivos que levaram a mulher a optar pela cesárea. É uma pesquisa qualiquantitativamente que teve como questão norteadora "porque você escolheu a cesárea"? Verificou-se que a escolha se deu em função do medo das mulheres em relação a dor do parto, pela própria solicitação das mulheres, por escolha dos profissionais e por falta dos conhecimentos de risco e benefícios do parto cesárea e do parto normal. Concluímos que são necessárias ações especiais desempenhadas pelas enfermeiras durante a assistência pré-natal, através de orientações e informações; participação das mulheres nos programas de preparao para o parto, capacitação dos profissionais para realização do parto normal e realização do parto pela enfermeira obstétrica.

Cesárea na apresentaçäo pélvica / Cesarean section in pelvic presentation

A revisäo da literatura e nossa própria experiência clínica levam-nos a propor que se permita a prova de parto vaginal em apresentaçäo pélvica quando näo há outras patologias maternas ou fetais de importância, pélvis materna de diâmetros normais , peso fetal estiamdo entre cerca de 2000g e claramente menor que 4000 g e na ausência de hiperextensäo da cabeça fetal. Essa prova de trabalho será considerada fracassada e se procederá ao parto por cesárea se houver a descida prévia de um ou ambos os pés com dilataçäo incompleta, se o período de dilataçäo prolongar-se por mais de que 18 horas ou se a única outra alternativa for a realizaçäo de manobras de extraçäo fetal