Parto vaginal operatório / Operative vaginal delivery

PONTOS-CHAVE Quando utilizados na técnica correta, fórcipes e vácuo-extratores apresentam baixos índices de complicações. Para o feto com sinais de hipóxia no período expulsivo, o parto vaginal operatório tem potencial para reduzir a exposição aos fatores intraparto que promovem a encefalopatia hipóxico-isquêmica. Fórcipes médios e/ou rotacionais são opções apropriadas em circunstâncias selecionadas e exigem habilidade e experiência. Os fórcipes são mais resolutivos do que os vácuo-extratores para o parto vaginal operatório, porém são mais associados a lacerações perineais graves. Céfalo-hematoma é mais provável de ocorrer com o aumento na duração da vácuo-extração. Os vácuo-extratores de campânulas flexíveis apresentam taxas maiores de falha, porém apresentam menores incidências de trauma no couro cabeludo do neonato. (AU)

Operative vaginal delivery: practice patterns and outcomes at a tertiary general hospital

INTRODUCTION@#There has been a global decrease in operative vaginal deliveries, with a marked shift towards the vacuum extractor. However, little is known about the trends in operative vaginal delivery in Singapore.@*METHODS@#A retrospective study was conducted on all operative vaginal deliveries performed from 2012 to 2017 at Singapore General Hospital (SGH). Maternal outcomes in terms of postpartum haemorrhage and obstetric anal sphincter injuries were compared between forceps- and vacuum-assisted deliveries. Neonatal outcomes in terms of neonatal intensive care unit (NICU) admission and clinically significant neonatal events were compared. The instrument preference of obstetricians was analysed.@*RESULTS@#A total of 906 consecutive operative vaginal deliveries were included in the study, comprising 461 forceps- and 445 vacuum-assisted deliveries. The rate of operative vaginal delivery was maintained at approximately 10% from 2012 to 2017. Neonatal cephalohematomas were more common after vacuum-assisted deliveries. Other maternal and neonatal outcomes did not differ significantly between the two groups. Clinically significant neonatal events were mostly due to shoulder dystocia, whereas all cases of NICU admissions were not directly related to the mode of delivery. Obstetricians' choice of instrument appeared to reflect personal preference and was not affected by the year of graduation.@*CONCLUSION@#The rates of neonatal and maternal morbidity were low at SGH. Overall instrument use of forceps and vacuum was balanced, and proficiency in both was demonstrated by all operators. Operative vaginal delivery remains an essential skill in facilitating safe vaginal delivery, which should be maintained to keep Caesarean section rates in check.

Estimación de la frecuencia del parto vaginal instrumentado en Colombia en los años 2015 - 2019. Estudio transversal de registros poblacionales / Estimated frequency of instrumented vaginal delivery in Colombia between 2015 and 2019. Population registry-based cross-sectional study

Objetivos: evaluar la frecuencia del parto instrumentado en Colombia y por regiones entre el 2015 y 2019. Materiales y métodos: estudio de corte transversal a partir de registros poblacionales. Se incluyeron los registros de mujeres con edad gestacional mayor a 28 semanas y parto vaginal. Muestreo consecutivo. La información se obtuvo a partir del certificado de nacido vivo del Departamento Administrativo Nacional de Estadística (DANE). Se realizó la descripción de las variables sociodemográficas y clínicas. La frecuencia del parto instrumentado fue calculada y descrita por año y departamento. Resultados: se incluyeron 3.224.218 registros de recién nacidos vivos. De estos, 1.719.405 (53,33 %) correspondieron a partos vaginales, y 1.468.726 (45,55 %) a partos por vía cesárea. La frecuencia nacional del parto instrumentado entre el 2015 y 2019 fue de 36.087 nacimientos (1,11 %); Antioquia y Bogotá, D.C. fueron los lugares con mayor ocurrencia, 16.201 (4,5 %) y 13.686 (2,52 %), respectivamente. Conclusiones: el parto vaginal instrumentado es la vía de parto con menor ocurrencia en Colombia con tendencia a la disminución. La formación en este recurso para el uso durante el trabajo de parto no debe perderse en la formación del profesional de salud, especialmente en los programas de Ginecología y Obstetricia. Se debe evaluar si el aumento en el adecuado uso de esta técnica puede disminuir la tasa de cesáreas observadas actualmente, así como describir los escenarios clínicos donde su uso es seguro para la madre y el feto. Se requieren estudios prospectivos, pues pueden permitir establecer las causas del descenso en el uso de esta herramienta obstétrica, los resultados maternos y perinatales en términos de su riesgo/beneficio.

Objectives: To assess the frequency of instrumented delivery in Colombia and by regions between 2015 and 2019. Materials and methods: Cross-sectional study based on population registries. Records of women with a gestational age of more than 28 weeks and vaginal delivery were included. Consecutive sampling was used. The information was taken from live birth certificates of the National Administrative Department of Statistics (DANE). Sociodemographic and clinical variables were described. The frequency of instrumented deliveries was calculated and described by year and by department. Results: Overall, 3,224,218 live birth records were included. Of these 1,719,405 (53.33 %) were vaginal deliveries and 1,468,726 (45.55 %) were cesarean births. At a national level, the frequency of instrumented deliveries between 2015 and 2019 was 36,087 births (1.11 %); Antioquia and Bogotá, D.C. were the places with the highest occurrence, with 16,201 (4.5 %) and 13,686 (2.52 %), respectively. Conclusions: The occurrence of instrumented vaginal delivery in Colombia is the lowest and tends to diminish. Training of healthcare professionals in this approach during labor must not be abandoned, particularly in Obstetrics and Gynecology training programs. Further studies should be conducted to determine whether the increased adequate use of this technique could contribute to a lower rate of cesarean sections, and also to describe the clinical setting in which its use is safe for both the mother and the fetus. Prospective studies are required to identify the causes leading to the lower use of this obstetric tool as well as the risks and benefits in terms of maternal and perinatal outcomes.

Análise da percepção de puérperas sobre a assistência ao parto em uma maternidade do Tocantins / Analysis of the perception of puerperal women about maternity care assistance in a maternity of Tocantins

Objetivo: No decorrer dos séculos, o parto migrou do ambiente domiciliar para o hospitalar, sendo então repleto de procedimentos que, embora tenham o intuito de ajudar, nem sempre são adequados ou baseados em evidências. Por isso, o objetivo deste estudo é identificar os procedimentos realizados com parturientes durante o parto em uma maternidade do Tocantins, além de caracterizar o perfil dessas pacientes. Método: Foi aplicado um questionário a 70 puérperas de parto normal, maiores e menores de idade, durante quatro meses. O questionário de referência foi o utilizado do estudo Nascer no Brasil. Resultados: A maioria das pacientes se autodeclarou parda, tinha ao menos o ensino médio completo e era maior de 18 anos. Mais da metade delas tiveram alguma alteração no períneo, 25% sofreram manobra de Kristeller e 88% submeteram-se à litotomia. Além disso, a grande maioria avaliou o serviço da maternidade como bom/ótimo/excelente. Conclusão: A assistência ao parto no Tocantins ainda se divide em práticas adequadas e técnicas ultrapassadas. Trata-se de um estudo original e um dos primeiros nesse sentido realizado no estado mais novo do Brasil.(AU)

Objective: Throughout the centuries, childbirth has migrated from the home environment to the hospital, being then full of procedures that although they are intended to help, are not always adequate or based on evidence. Therefore, the objective of this study is to identify the procedures performed with parturients during childbirth in a maternity hospital in Tocantins, in addition to characterizing the profile of these patients. Method: A questionnaire was applied to 70 mothers of normal birth, older and younger, for four months. The reference questionnaire was used in the Nascer no Brasil study. Results: Most patients declared themselves to be brown, had at least completed high school, and were over 18 years old. More than half of them had some alteration in the perineum, 25% underwent a Kristeller maneuver and 88% underwent lithotomy. In addition, the vast majority rated the maternity service as good/excellent/excellent. Conclusion: Assistance to childbirth in Tocantins is still divided into outdated technical and appropriate practices. This is an original study and one of the first in this sense carried out in the newest state of Brazil.(AU)

Exploring obstetrical interventions and stratified cesarean section rates using the Robson classification in tertiary Care hospitals in the united arab emirates

Abstract Objective The objective of the present study was to explore obstetric management in relation to clinical, maternal and child health outcomes by using the Robson classification system. Methods Data was collected from obstetrics registries in tertiary care hospitals in Dubai, United Arab Emirates (UAE). Results The analysis of > 5,400 deliveries (60% of all the deliveries in 2016) in major maternity hospitals in Dubai showed that groups 5, 8 and 9 of Robson's classification were the largest contributors to the overall cesarean section (CS) rate and accounted for 30% of the total CS rate. The results indicate that labor was spontaneous in 2,221 (45%) of the women and was augmented or induced in almost 1,634 cases (33%). The birth indication rate was of 64% for normal vaginal delivery, of 24% for emergency CS, and of 9% for elective CS.The rate of vaginal birth after cesarean was 261(6%), the rate of external cephalic version was 28 (0.7%), and the rate of induction was 1,168 (21.4%). The prevalence of the overall Cesarean section was 33%; with majority (53.5%) of it being repeated Cesarean section. Conclusion The CS rate in the United Arab Emirates (UAE) is higher than the global average rate and than the average rate in Asia, which highlights the need for more education of pregnant women and of their physicians in order to promote vaginal birth. A proper planning is needed to reduce the number of CSs in nulliparous women in order to prevent repeated CSs in the future. Monitoring both CS rates and outcomes is essential to ensure that policies, practices, and actions for the optimization of the utilization of CS lead to improved maternal and infant outcomes.

Comparison of Caesarean sections and instrumental deliveries at full cervical dilatation: a retrospective review

INTRODUCTION@#This study aimed to compare instrumental vaginal deliveries (IDs) and Caesarean sections (CSs) performed at full cervical dilatation, including factors influencing delivery and differences in maternal and neonatal outcomes.@*METHODS@#A retrospective review was conducted of patients who experienced a prolonged second stage of labour at Singapore General Hospital from 2010 to 2012. A comparison between CS and ID was made through analysis of maternal/neonatal characteristics and peripartum outcomes.@*RESULTS@#Of 253 patients who required intervention for a prolonged second stage of labour, 71 (28.1%) underwent CS and 182 (71.9%) underwent ID. 5 (2.0%) of the patients who underwent CS had failed ID. Of the maternal characteristics considered, ethnicity was significantly different. Induction of labour and intrapartum epidural did not influence delivery type. 70.4% of CSs occurred outside office hours, compared with 52.7% of IDs (p = 0.011). CS patients experienced a longer second stage of labour (p < 0.001). Babies born via CS were heavier (p < 0.001), while the ID group had a higher proportion of occipitoanterior presentations (p < 0.001). Estimated maternal blood loss was higher with CSs (p < 0.001), but neonatal outcomes were similar.@*CONCLUSION@#More than one in four parturients requiring intervention for a prolonged second stage of labour underwent emergency CS. Low failed instrumentation rates and larger babies in the CS group suggest accurate diagnoses of cephalopelvic disproportion. The higher incidence of CS after hours suggests trainee reluctance to attempt ID. There were no clinically significant differences in maternal and neonatal morbidity.

Embarazo, trauma obstétrico y sus efectos sobre el piso pélvico. Revisión de la literatura / Pregnancy, obstetric trauma and their effects on the pelvic floor. Literature review / Gravidez, trauma obstétrico e seus efeitos sobre o piso pélvico. Revisão da literatura

Los trastornos del piso pélvico son una condición que afecta al 30% de las mujeres de todas las edades, e incluyen un abanico de patologías anatómicas y funcionales que, aunque no alteran la supervivencia de las pacientes, sí afectan en gran medida su calidad de vida. Dentro de estas patologías encontramos la incontinencia urinaria y fecal, el prolapso de órganos pélvicos y la disfunción sexual. La importancia del tema radica en que los trastornos del piso pélvico son más frecuentes después del embarazo y el parto por los cambios inherentes al embarazo mismo y por el trauma obstétrico que son factores de riesgo conocidos y que pueden estar asociados con secuelas graves del piso pélvico. Es por ello que se deben prever posibles complicaciones en el trabajo de parto que puedan aumentar el riesgo de trastornos del piso pélvico e implementar ciertas estrategias de prevención y de intervenciones seguras, que minimicen los daños y las secuelas que se producen en el largo plazo. A continuación haremos una revisión de la literatura sobre los cambios fisiológicos del embarazo en el piso pélvico, los trastornos disfuncionales más frecuentes, el papel del parto intervenido en la aparición de estos trastornos y las estrategias de prevención que pueden implementarse para disminuir los efectos sobre el piso pélvico.

Pelvic floor disorders are a medical condition that affects 30% of women of all ages, and include a plethora of anatomical and functional pathologies that, though they do not alter patient survival, do affect their well-being to a large extent. Urinary and fecal incontinence, pelvic organ prolapse and sexual dysfunction are among these pathologies. The importance of the subject rests on the fact that pelvic floor disorders are more frequent after pregnancy and birth as a result of inherent changes to pregnancy itself and obstetric injuries that are widely known risk factors, which may be associated to severe damage to the pelvic floor. Therefore, possible labor complications that may increase the risk of pelvic floor disorders must be prevented, along with the implementation of certain preventive strategies and safe interventions that reduce damage and possible long-term consequences. Here, we present a literature review about the physiological changes in the pelvic floor during pregnancy, the most frequent dysfunctional disorders, the role of forceps delivery in the appearance of different conditions, and preventive strategies that may be implemented to reduce the effects on the pelvic floor.

Os transtornos do piso pélvico são uma condição que afeta a 30% das mulheres de todas as idades, e incluem um leque de patologias anatómicas e funcionais que, embora não alteram a supervivência das pacientes, sim afetam em grande medida sua qualidade de vida. Dentro destas patologias encontramos a incontinência urinaria e fecal, o prolapso de órgãos pélvicos e a disfunção sexual. A importância do tema radica em que os transtornos do piso pélvico são mais frequentes depois da gravidez e do parto pelas mudanças inerentes à gravidez em si e pelo trauma obstétrico que são fatores de risco conhecidos e que podem estar associados com sequelas graves do piso pélvico. É por isso que se devem prever possíveis complicações no trabalho de parto que possam aumentar o risco de transtornos do piso pélvico e implementar certas estratégias de prevenção e de intervenções seguras, que minimizem os danos e as sequelas que se produzem em longo prazo. A continuação faremos uma revisão da literatura sobre as mudanças fisiológicas da gravidez no piso pélvico, os transtornos disfuncionais mais frequentes, o papel do parto intervindo na aparição destes transtornos e as estratégias de prevenção que podem implementar-se para diminuir os efeitos sobre o piso pélvico.

Cardiomiopatia hipertrófica e gravidez / Hypertrophic cardiomyophaty and pregnancy

A cardiomiopatia hipertrófica (CMH) é doença incomum na gestação, caracterizada pela hipertrofia do ventrículo esquerdo, com expressão fenotípica e manifestações clínicas variáveis. O diagnóstico pode ser confirmado pelo ecocardiograma com Doppler. Trata-se de enfermidade bem tolerada na gestação, entretanto, pode desencadear insuficiência cardíaca congestiva, com grave comprometimento materno e perinatal. O tratamento para a gestante com CMH depende da obstrução do fluxo do ventrículo esquerdo. Em paciente sintomática portadora da forma obstrutiva, devem-se evitar grandes perdas sanguíneas e uso de drogas vasodilatadoras durante o trabalho de parto. O parto vaginal mostrou-se seguro, mas o período expulsivo deve ser abreviado com uso de fórceps naquelas que apresentam sintomatologia obstrutiva. Raras complicações podem acontecer, o que requer planejamento do parto e adequada monitorização materna e fetal. (AU)

The Hypertrophic Cardiomyopathy (HCM) is an uncommon condition during pregnancy, which attends with a left ventricular hypertrophy, and phenotypic expression and clinical are both variable. The diagnosis can be confirmed by Doppler echocardiography. Several studies show that it is a disease well tolerate during pregnancy, however it may trigger congestive heart failure with severe maternal and perinatal commitment. The treatment of pregnant patients with HCM depends on the presence of symptoms caused by obstruction of the left ventricle. In symptomatic patient carrying the obstructive form should be avoided large blood loss and use of vasodilator drugs during labor. Vaginal delivery is safe, but the expulsive period should be abbreviated with the use of forceps in those with obstructive symptoms. Rare complications can occur and therefore it is necessary a delivery planning and an adequate maternal and fetal monitoring. (AU)

Indicações do parto a fórceps / Indications for forceps deliveries

A solução do parto no período expulsivo é um desafio, ainda nos dias de hoje. Apesar de ser praticado em cerca de 10% dos partos no mundo ocidental, há discussões sobre as indicações do parto vaginal operatório, a escolha do instrumento e sua aplicação sequenciada. Foi feita revisão da literatura, que se mostrou pobre em ensaios clínicos. A evidência maior do uso do fórceps repousou em estudos observacionais, muito dos quais com tamanho amostral limitado. Também, foram consultadas as diretrizes de algumas sociedades (ACOG, SOGC, RCOG e FEBRASGO) para as recomendações. Concluiu-se que ainda há necessidade da prática do fórceps, mas que esse ato deve ser realizado por obstetra experiente e em ambiente que permita a prática da cesárea. As indicações fetais para parto a fórceps são a parada de progressão e o sofrimento fetal, e as indicações maternas são aquelas em que o esforço expulsivo é fator de risco para complicações (cardiopatias, pneumopatias, encefalopatias). A falha do fórceps ou do vácuo é indicação para cesárea, não sendo recomendado o seu uso sequenciado. Foi verificado que há necessidade de programas de treinamento na prática do fórceps.

The solution of second stage of childbirth is still a challenge. Despite being practiced in 10% of births in the Western world, there are discussions about the indications for operative vaginal deliveries, choice of instrument and its application. Literature review was conducted, which proved to be poor in clinical trials. The best evidence rested in observational studies, many of which with limited sample size. Some guidelines were consulted (ACOG, SOGC, RCOG and FEBRASGO) for recommendations. It was concluded that there is still need for the practice of forceps, but this surgery must be performed by experienced obstetrician and in an environment that allow the practice of caesarean section. Fetal indications for forceps deliveries are lack of progression in the second stage and fetal distress. Maternal indications are those in which the expulsive effort is risk factor for complications (heart, lung or cerebral diseases). The failure of the forceps or vacuum is indication of caesarean section, not being recommended its use in sequence. There is a need for training programs in the practice of forceps.

Neonatal outcome with instrumental vaginal delivery: a study at PNS Shifa

To evaluate neonatal outcome in terms of Apgar score after forceps and ventouse delivery in pregnant ladies indicated to have instrumental deliveries. Randomized control trial. This study was conducted at Labor ward of department of obstetrics and gynecology, PNS SHIFA Karachi, between Dec 2007 to Mar 2008. The target population were all pregnant subjects who visited labor room for delivery. Out of these patients, subjects who were indicated an assisted vaginal delivery for necessary management of labor were formally requested to participate in the study after various exclusions. Instrumentation was done in only those patients with singleton term pregnancy with cephalic presentation and vertex at + 1 to +3 stations. Patients with an indication for assisted vaginal delivery [n=105], were randomized for ventouse [n=53] and forceps delivery [n=52]. Instruments used were Wrigley's outlet forceps and vacuum extractor [V.E] with silicone cups. Data was recorded on specially designed Proforma. Post delivery neonatal outcome in terms of Apgar score at one minute and five minutes were compared between two modalities. The subjects undergoing forceps delivery had a significantly higher Apgar score [8.36 +/- 1.27] at 1 minute in comparison to those subjected to vacuum delivery [7.53 +/- 1.56]. The differences in Apgar score at 5-minutes [forceps delivery: 9.136 + 1.01 vs vacuum delivery 9.00 + 1.19], were not statistically significant. Outlet forceps assisted vaginal deliveries had better neonatal outcome in terms of Apgar score in comparison to ventouse

Aplicabilidad de simuladores de mediana complejidad en el proceso de formación de residentes de ginecología y obstetricia / Use of simulators in the process of residency training in obstetric and gynecology

Antecedentes: El entrenamiento de técnicas quirúrgicas durante la formación de gineco-obstetras encuentra dificultades por razones de seguridad de la paciente y del recién nacido. Una de las estrategias utilizadas es el uso de simuladores para facilitar la adquisición de las habilidades necesarias para resolver situaciones críticas frecuentes en la práctica médica, salvaguardando la ética en la enseñanza y mejorando su calidad. Objetivos: Evaluar el uso de simuladores de parto interactivo de mediana complejidad (Noelle® Gaumard Scientific, Miami, FL) como método de educación médica para adquirir las destrezas necesarias en la atención de un parto operatorio con Espátulas de Thierry. Método: Diseño: estudio piloto prospectivo controlado. Sujetos: seis médicos en formación de la especialidad de la Universidad de los Andes. Se definieron aleatoriamente 2 grupos estratificados por año de formación. A todos se les instruyó en sesión teórica sobre el uso de las espátulas. La mitad tuvo una sesión práctica. Se utilizó un simulador y pautas estandarizadas para evaluar la adquisición de habilidades. Resultados: Se expresó según el porcentaje del puntaje máximo logrado para cada prueba. El grupo experimental tuvo un resultado en la evaluación práctica de 90/25/90 por ciento. El grupo control 35/70/65 por ciento. Se observó menos diferencias inter grupos en la prueba teórica. Conclusión: Las habilidades asociadas al uso de las espátulas de Thierry se adquirieron más completamente en el grupo expuesto a un taller con simuladores de mediana complejidad.

Background: The training on surgical techniques during the instruction of obstetrician-gynecologists finds some difficulties because of patient and newborn's safety concern. One of the strategies is to use simulators that facilitate the acquisition of the skills required to solve critical situations, common in medical practice. Objective: To evaluate the use of simulators (NoelleÕ Gaumard Scientific, Miami, FL) in medical education as a mean to acquire the skills needed for an instrumental delivery using Thierry's spatulas. Methods: Design: prospective controlled pilot study. Participants: six medical residents of obstetrics and gynecology from Los Andes University. They were randomized on two groups stratified by years of resideney. All of them received a lecture on Thierry's spatulas. Half of them also had a workshop. A simulator and standardized guidelines were used to evaluate the skills acquisition. Results: They were stated by the percentage of maximum score achieved to each test. The experimental group had a practical score of 90/25/90 percent. The control group got 35/70/65 percent. There were few differences in the written test between groups. Conclusion: The experimental group showed a better performance in the use of Thierry's spatulas.

Espátulas de Velasco y de Thierry / Velasco's spatula and thierry's spatula

Las espátulas del parto son instrumentos fabricados de acero inoxidable de forma cóncava en su extremo superior o distal, sin articulación y con un mango en su extremo proximal para sujetarlo. Son utilizadas en distocias del parto ya que permiten la abertura del canal del parto facilitando la salida del feto en la fase expulsiva. Existen dos tipos de espátulas de parto: de Velasco y de Thierry. Las espátulas de Velasco son más pequeñas y rectas; las de Thierry son más grandes y presentan una ligera curvatura en su extremo superior. Para tener una mejor idea de como actúan las espátulas, éstas se comparan con el calzador del zapato, cuya función es ayudar a deslizar.

Labor spatulas are stainless steel fabricated instruments, concave in the upper or distal extreme, without articulation and with a handle on its proximal extreme for holding it. These spatulas are used in labor dystocias because it helps the labor canal and the fetus exit in the expulsive stage. There are two labor spatula types: Velasco’s and Thierry’s. Velasco's spatula are smaller and straight, Thierry’s ones are bigger and show a slight curvature on their upper extreme. To have a better idea of how spatulas work, they are compared to a shoehorn, whose function is to help slide.

Fórceps de Leff: nueva técnica de aplicación / Leff forceps: new application technique

Presentar una nueva técnica de aplicación de fórceps de Leff para la rotación del polo cefálico en variedad transversa a variedad occipito-púbica. Estudio descriptivo, analítico donde se aplicó la técnica a 42 pacientes en trabajo de parto que presentaban variedades transversas persistentes o que ameritaban disminuir el tiempo del período expulsivo. Maternidad “Concepción Palacios”. Caracas. Se logró la rotación del polo cefálico de variedades transversas a occipito púbica con éxito. La duración del trabajo de parto en promedio fue 8 horas y 51 minutos hasta el período expulsivo; 24 minutos en promedio de duración del período expulsivo y un tiempo total del trabajo de parto en 8 horas y 54 minutos, la rotura de membranas fue en el 64,28 por ciento en forma artificial; el líquido amniótico fue claro con grumos en el 95,24 por ciento de los casos; el sangrado posparto fue fisiológico en el 97,6 por ciento de ellos; se aplicó fórceps de Leff asociado a fórceps tractor en el 78,57 por ciento de los casos, se aplicó en III plano de Hodge en el 88,1 por ciento, se obtuvo una rotación exitosa del polo cefálico en todos los casos documentados siendo 97,6 por ciento a la variedad occipito-púbica y el 2,40 por ciento a occipito-sacra; en 9 casos se apreció desgarro vaginal grado I y grado II en menor proporción; se administró anestesia epidural en 76,19 por ciento de los casos; el tiempo de estancia hospitalaria fue de 2 y 3 días en el 85,71 por ciento de los casos; la evolución de la madre fue satisfactoria en el 100 por ciento de los casos; el Apgar del recién nacido al primer minuto: 7 puntos, 5 minutos: 9 puntos en promedio; el peso promedio fue: 3 133 g. Se concluye que la técnica demuestra ser más sencilla su aplicación, altamente efectiva, de fácil aprendizaje por lo que recomendamos su enseñanza a los médicos residentes.

Lesão esfincteriana e continência anal em pós-parto vaginal / Sphincter injury and anal continence after vaginal

Incontinência anal (IA) é definida pela perda involuntária de gases, fezes líquidas ou sólidas. Entre várias causas de IA, o trauma obstétrico é causas primária de lesão esfincteriana anal (LEA) e tem sido foco de pesquisa, tratamento e prevenção. Este trabalho tem por objetivo revisar incidência , fatores de risco e medidas que previnam e/ ou reduzam o trauma obstétrico sobre a continência anal.

Case of unusual foreign body in the rectum

A 44-year-old male patient with a foreign body in rectum [beverage bottle], introduced as sexual perversion, is presented with literature review. The management emphasis is on transanal retrieval and ruling out of the rectal and colonic perforation and the requirement for postremoval psychiatric treatment

Fórcipe obstétrico / Obstetrics forcips

O fórcipe não é instrumento do passado. Cerca de 15% dos partos são terminados a fórcipe nas maternidades públicas do Brasil. Quando bem indicado e bem aplicado torna-se instrumento salvador e não malfeitor, como faz parecer a muitos. Um motivo que levou o fórcipe ser considerado por alguns um instrumento antiquado ou inadequado foi a falta de ensinamento, principalmente prático, nas escolas de medicina. Outro motivo foi o avanço da eventual alternativa de término da gestação: a operação cesariana. O American College of Obstetrics and Ginecology recomenda o treinamento do parto instrumental vaginal para controle e redução das taxas de operação cesareana. O uso d fórcipe permanece como melhor opção, durante o período expulsivo, para assegurar o bem-estar materno-fetal, quando aplicado com técnica e indicação precisas.