Protocolo de atendimento no parto, puerpério e abortamento durante a pandemia da COVID-19 / Childbirth, Puerperium and Abortion Care Protocol during the COVID-19 Pandemic

O novo coronavírus (SARS-Cov-2) é um vírus que causa doença respiratória potencialmente grave e que se propagou em diversos países, atingindo todas as faixas etárias, incluindo gestantes. O objetivo deste protocolo é dar suporte técnico-científico aos obstetras brasileiros quanto ao atendimento ao parto, puerpério e abortamento durante a pandemia.(AU)

Structure and practices in hospitals of the apice ON project: a baseline study / Estrutura e práticas de hospitais integrantes do projeto apice ON: estudo de linha de base

ABSTRACT OBJECTIVE To describe some characteristics of the 97 teaching hospitals participating in the Projeto de Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia (Apice ON—Project for Improvement and Innovation in Care and Teaching in Obstetrics and Neonatology). METHODS The semester prior to the beginning of the program was adopted as the baseline to evaluate the subsequent structural and processes changes of this project. Secondary data from the first half of 2017 were extracted from the National Registry of Health Establishments (NRHE), the Hospital Information System and the Sistema de Informações sobre Nascidos Vivos (SINASC—Live Birth Information System). RESULTS Before the implementation of the project, only 66% of the hospitals had a Baby-friendly Hospital Initiative, only 3% offered special accommodations for high-risk pregnant women, mothers and their newborns, and 45.4% hospitals adopted the skin-to-skin contact; 97% hospitals had separate rooms for pre-labor and vaginal delivery (93%), not following the recommendations of the Ministry of Health; nine hospitals (9%) had no rooming-in; there were few obstetrics nurses (less than 1% of professionals enrolled in the NRHE), and in only six hospitals the proportion of births assisted by this professional was above 50% of vaginal deliveries, while in eight this percentage ranged between 15% and 50%; the average cesarean section rate was 42%, ranging between 37.6% (Southeast) and 49.1% (Northeast); ten hospitals did not charge for companions according to inpatient hospital authorization. CONCLUSION The study strengthens the relevance of the Apice ON project as an inducer of change of the care model in teaching hospitals and, therefore, as a strategy for the implementation of the national public policy represented by the Stork Network.

RESUMO OBJETIVO Este artigo descreve algumas características dos 97 hospitais de ensino participantes do Projeto de Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia (Apice ON). MÉTODOS Foi adotado como linha de base o semestre anterior ao lançamento do programa, para permitir avaliar as mudanças estruturais e processuais decorrentes desse projeto. Utilizaram-se dados secundários referentes ao primeiro semestre de 2017 disponíveis no Cadastro Nacional de Estabelecimentos de Saúde (CNES), no Sistema de Informações Hospitalares e no Sistema de Informações sobre Nascidos Vivos. RESULTADOS Antes da implantação do projeto, apenas 66% dos hospitais apresentaram habilitação de Hospital Amigo da Criança, somente 3% estavam habilitados com Casa da gestante, Bebê e Puérpera e 45,4% adotavam o método canguru; 97% dispunham de sala de pré-parto e 93% de sala de parto normal separadas, sem seguir o preconizado pelo Ministério da Saúde; nove hospitais (9%) não tinham alojamento conjunto; havia poucos enfermeiros obstetras (menos de 1% dos profissionais cadastrados no CNES), e em apenas seis hospitais a proporção de partos assistidos por esse profissional foi superior a 50% dos partos vaginais, enquanto em oito hospitais esta proporção ficou entre 15 e 50%; a taxa média de cesáreas foi de 42%, variando entre 37,6% (Sudeste) e 49,1% (Nordeste); em dez dos hospitais não constava cobrança de diária de acompanhante na autorização de internação hospitalar. CONCLUSÃO O estudo fortalece a pertinência do projeto Apice ON como indutor de mudança do modelo nos hospitais de ensino e, portanto, como estratégico para a efetivação da política pública nacional representada pela Rede Cegonha.

Morbilidad materna extremadamente grave. Un problema obstétrico en la salud pública y la atención al paciente grave / Extremely serious maternal morbidity. An obstetric problem in public health and seriously ill patient care

El concepto morbilidad materna extremadamente grave, se considera de gran utilidad al ser un indicador muy asociado a la muerte materna y un estadio intermedio en prácticamente la totalidad de las fallecidas. Como parte de la primera etapa de un proyecto de investigación se realizó una revisión del tema y se consultaron las bases de datos LILACS, EBSCO e HINARI. Los descriptores que se utilizaron fueron: mortalidad materna, morbilidad y paciente obstétrica grave. Los resultados de la búsqueda se limitaron a los últimos cinco años en idioma inglés, español, francés y portugués. La morbilidad materna extremadamente grave es un indicador muy asociado a la muerte materna y es considerada una alternativa válida para utilizarla como indicador de la calidad de los cuidados maternos. El interés creciente de integrar el análisis de la morbilidad materna extremadamente grave al estudio de la mortalidad materna, permite identificar los factores de riesgo presentes en las gestantes, desde un embarazo sin complicaciones hasta la muerte, pues se presenta en un mayor número de casos, y con el manejo de aquellos que evolucionaron favorablemente después de la gravedad extrema, se pueden evitar nuevas defunciones (AU).

The concept "extremely serious maternal morbidity" is considered very useful because it is an indicator closely associated to maternal death and an intermediate stage in practically the totality of maternal deceases. As a part of the first stage of a research project, a review on the theme was carried out, and LILACS, EBSCO and HINARI data bases were consulted. The used descriptors were: maternal mortality, morbidity and seriously ill obstetric patient. The results of the search were limited to the last five years in English, Spanish, French and Portuguese languages. Extremely serious maternal morbidity is an indicator very frequently associated to maternal death, and it is considered a suitable alternative for using it as an indicator of the maternal care quality. The increasing interest for integrating the analysis of extremely serious maternal morbidity to the study of maternal morbidity allows identifying the risk factors that are present in pregnant women, beginning from a pregnancy without complications and ending with death, because they are found in a bigger quantity of cases, and new deceases could be avoided with the management of those favourably evolving after the extreme seriousness (AU).

Assistência ao parto e presença do acompanhante: um estudo sobre as jovens do Inquérito Nacional sobre Parto e Nascimento - "Nascer no Brasil" / Assistance in childbirth and the companions presence a study on the young women of the National Survey on Childbirth and Birth - "Born in Brazil"

Introdução: Estudos sobre a assistência ao parto de mulheres jovens são escassos no país, sobretudo considerando a perspectiva e especificidade das questões envolvidas sobre a reprodução na juventude e das práticas utilizadas com os preceitos da humanização do nascimento na assistência obstétricas voltada para as jovens. Sabe-se que adoção de práticas obstétricas úteis e a presença do acompanhante (suporte contínuo) durante o processo do nascimento traz benefícios aos desfechos maternos e perinatais. Estas práticas são consideradas como bons indicadores para avaliar a qualidade da assistência obstétrica prestada às mulheres. Objetivos: analisar a assistência obstétrica e a presença do acompanhante durante o trabalho de parto e parto das jovens de risco obstétrico habitual entrevistadas no Inquérito Nacional sobre Parto e Nascimento Nascer no Brasil, Região Sudeste; analisar a qualidade da assistência ao parto oferecida às jovens, a partir do exame dos dados sobre as práticas obstétricas; caracterizar a assistência ao parto e descrever a presença do acompanhante, segundo os dois grupos etários de jovens. Métodos: Estudo transversal, a partir dos dados do Inquérito Nacional sobre Parto e Nascimento Nascer no Brasil (NNB), com coleta de dados realizada entre os anos de 2011 e 2012. No presente estudo, a amostra foi composta por 1.212 mulheres jovens entrevistadas pelo inquérito NNB, pertencentes aos hospitais da região Sudeste. Os critérios de inclusão neste estudo foram: mulheres de risco obstétrico habitual com até 24 anos de idade. A análise e a comparação dos dados foram realizadas a partir de dois grupos de mulheres: mulheres entre 13 a 18 anos (adolescentes) e as mulheres entre 19 a 24 anos. A associação entre os grupos de jovens e as variáveis estudadas foi realizada pela análise descritiva bivariada. Foi verificada a associação entre os grupos por meio do teste de associação qui-quadrado de Pearson (x2), com nível de significância de 5 por cento (p < 0,05). Resultados: Foram encontradas altas prevalências de práticas prejudiciais para a condução do trabalho de parto e nascimento das jovens mulheres, como a posição de litotomia (93,6 por cento ), o uso do cateter venoso periférico (70,9 por cento ), restrição de dieta e líquidos (68 por cento ), amniotomia (57,1 por cento ), ocitocina (53,6 por cento ), episiotomia (49,9 por cento ) e a manobra de Kristeller (40,9 por cento ) e houve baixa utilização das práticas consideradas úteis e adequadas para a atenção ao parto, tais como: medidas não farmacológicas de alívio para dor (39,9 por cento ), contato pele-a-pele logo após o nascimento (35,5 por cento ), amamentação na sala de parto (21,3 por cento ) e posição não-supina (5,7 por cento ). Os índices foram capazes de caracterizar a assistência ao parto, demonstrando uma qualidade aquém da desejável. Apenas 25 por cento das jovens tiveram a presença do acompanhante conforme a lei 11.108/05. As jovens de 13 a 18 anos apresentaram prevalência maior de intervenções durante a assistência ao nascimento, apesar de terem sido mais acompanhadas em todos os momentos da internação, em relação as jovens de 19 a 24 anos. Conclusões: Constatou-se que o modelo de assistência oferecido às jovens foi marcado pela presença de intervenções desnecessárias e o baixo uso das boas práticas. A presença do acompanhante não esteve associada a uma menor magnitude de práticas prejudiciais ocorridas no trabalho de parto e parto das jovens

Background: Studies with regards to childbirth assistance of young women are scarce in our country, especially when considering the perspective and specificity of the issues involved in the reproduction among youth and the practices used with the precepts of the humanization of birth in obstetric care for young women. It is known that the adoption of useful obstetrical practices and the presence of the companion (i.e. continuous support) during the birth process bring benefits to both maternal and perinatal outcomes. Such practices are considered as positive indicators when assessing the quality of obstetric care provided to women. Objectives: To analyze obstetric care and the presence of the companion during labour and the delivery of young women at habitual obstetric risk interviewed in the National Birth and Birth Survey - \"Born in Brazil\"; to analyze the quality of delivery assistance offered to young women, based on the examination of data on obstetrical practices; to characterize delivery assistance and describe the presence of the companion, according to the two age groups of young women. Methods: A cross-sectional study based on data collected from the National Birth and Birth Survey - \"Born in Brazil\" (NNB), with data collection performed between 2011 and 2012. In the present study, the sample consisted of 1.212 young women interviewed by the NNB survey, belonging to hospitals located in the Southeast region. The inclusion criteria in such present study were: women of habitual obstetric risk up to 24 years of age. Data analysis and comparison were performed in two groups of women: women between the ages of 13 and 18 (adolescents) and women between the ages of 19 and 24. The association between the groups of young women and the studied variables was performed by the bivariate descriptive analysis. The association between the heretofore mentioned groups was verified by using the Pearson chi-square association test (x2), with a significance level of 5 per cent

Transplante renal e gestação / Kidney transplantation and pregnancy

O transplante renal é considerado o melhor tratamento para a doença renal terminal. Essa terapia tem avançado em diversos aspectos, contribuindo para que pacientes transplantadas em idade fértil possam ter uma gestação bem-sucedida. Foi conduzida revisão da literatura nas bases de dados Periódico Capes e PubMed/MEDLINE no período entre 1998 e 2013, visando melhor compreensão e acompanhamento de gestantes submetidas a transplante renal.O sucesso dessas gestações depende de vários fatores, incluindo planejamento pré-concepção minucioso baseado na saúde geral da paciente, função do enxerto, história de rejeição, pressão arterial sistêmica, proteinúria e ultrassom do enxerto. Há relatos de nascidos vivos em torno de 70% dessas gestações, com mortalidade perinatal de 10%, deterioração do enxerto em 5% dos casos, e média temporal entre o transplante e a gestação de aproximadamente três anos. As principais complicações foram maiores taxas de parto cesáreo, hipertensão arterial sistêmica e parto pré-termo. Embora a frequência de complicações perinatais descrita nessa população seja elevada, o transplante renal não é considerado uma contraindicação para a gestação. É necessário melhor avaliação dos efeitos dos agentes imunossupressores sobre o feto e o recém-nato para garantir segurança do uso dessas drogas durante a gestação e a amamentação.(AU)

Renal transplantation is considered the best treatment for end-stage renal disease. This therapy has advanced in many ways, contributing to transplanted patients of childbearing age can have a successful pregnancy. It was conducted a literature review in Capes Journal and PubMed/MEDLINE database between the period of 1998 and 2013, aiming at better understanding and monitoring of pregnant women who underwent renal transplantation. The success of these gestations depends on diverse factors, including a thorough preconception planning based on the patient general health, graft function, history of rejection, systemic blood pressure, proteinuria and graft ultrasound. There are reports of live births in about 70% of the gestations, with a perinatal mortality of 10%, graft deterioration in 5% of the cases, and temporal average between the transplantation and the gestation of approximately three years. The main complications were higher rates of cesarean delivery, systemic arterial hypertension and preterm birth. Although the frequency of perinatal complications described in this population is high, renal transplantation is not considered a contraindication to pregnancy. It is necessary better assessment of the imunossupressors agents effects on the fetus and newborns to ensure safety of the use of these drugs during pregnancy and breastfeeding.(AU)

Applying the new concept of maternal near-miss in an intensive care unit

OBJECTIVES: The World Health Organization has recommended investigating near-misses as a benchmark practice for monitoring maternal healthcare and has standardized the criteria for diagnosis. We aimed to study maternal morbidity and mortality among women admitted to a general intensive care unit during pregnancy or in the postpartum period, using the new World Health Organization criteria. METHODS: In a cross-sectional study, 158 cases of severe maternal morbidity were classified according to their outcomes: death, maternal near-miss, and potentially life-threatening conditions. The health indicators for obstetrical care were calculated. A bivariate analysis was performed using the Chi-square test with Yate's correction or Fisher's exact test. A multiple regression analysis was used to calculate the crude and adjusted odds ratios, together with their respective 95% confidence intervals. RESULTS: Among the 158 admissions, 5 deaths, 43 cases of maternal near-miss, and 110 cases of potentially lifethreatening conditions occurred. The near-miss rate was 4.4 cases per 1,000 live births. The near-miss/death ratio was 8.6 near-misses for each maternal death, and the overall mortality index was 10.4%. Hypertensive syndromes were the main cause of admission (67.7% of the cases, 107/158); however, hemorrhage, mainly due to uterine atony and ectopic pregnancy complications, was the main cause of maternal near-misses and deaths (17/43 cases of near-miss and 2/5 deaths). CONCLUSIONS: Hypertension was the main cause of admission and of potentially life-threatening conditions; however, hemorrhage was the main cause of maternal near-misses and deaths at this institution, suggesting that delays may occur in implementing appropriate obstetrical care.

change in trainee physicians' knowledge and comfort levels with obstetric emergencies following ALSO training

The Advanced Life Support in Obstetrics [ALSO] is a course in emergency obstetrics to help physicians and other health care providers develop and maintain the knowledge and skills to effectively manage potential obstetric emergencies. This course was held for the first time in Pakistan at the Aga Khan University in September 2003. This study was conducted to evaluate the improvement in knowledge and comfort level of physicians-in-training [interns, family medicine, obstetric and emergency room residents] in dealing with emergency obstetrics after undergoing the course. After informed consent, study subjects were administered a written test and asked to complete a questionnaire 10 days before and immediately after taking the ALSO course. Level of comfort in handling obstetric emergencies was assessed using a three-point Likert scale. A total of 38 trainees participated in pretest, ALSO course and subsequent post-test. Eleven were males and 27 were females. The comparison of the pre-test and post test showed a significant increase in the knowledge. The mean difference between the scores was 24 and the paired t-test done showed there was a highly significant difference between the scores [t=18.8, p= <0.001]. There was also a significant improvement in the comfort level for handling emergency obstetrics. Following the ALSO course all participants said they would recommend the course to others. The ALSO course is a valuable teaching intervention that improves not only knowledge but also perceived comfort levels of emergency obstetrics among interns and residents in a developing country

Unavailability of essential obstetric care services in a local government area of south-west Nigeria.

This paper reports the findings at baseline in a multi-phase project that aimed at reducing maternal mortality in a local government area (LGA) of South-West Nigeria. The objectives were to determine the availability of essential obstetric care (EOC) services in the LGA and to assess the quality of existing services. The first phase of this interventional study, which is the focus of this paper, consisted of a baseline health facility and needs assessment survey using instruments adapted from the United Nations guidelines. Twenty-one of 26 health facilities surveyed were public facilities, and five were privately owned. None of the facilities met the criteria for a basic EOC facility, while only one private facility met the criteria for a comprehensive EOC facility. Three facilities employed a nurse and/or a midwife, while unskilled health attendants manned 46% of the facilities. No health worker in the LGA had ever been trained in lifesaving skills. There was a widespread lack of basic EOC equipment and supplies. The study concluded that there were major deficiencies in the supply side of obstetric care services in the LGA, and EOC was almost non-existent. This result has implications for interventions for the reduction of maternal mortality in the LGA and in Nigeria.

Diagnosis summary and coding of obstetric conditions in the government hospitals in Pattalung Province, the effects of audit and feedback.

OBJECTIVE: Assess the effects of audit and feedback through a seminar on the obstetric summary and coding system with respect to the International Classification of Diseases, Tenth Revision (ICD-10) and to determine factors associated with the error of summary and coding audit. MATERIAL AND METHOD: The medical records of 1,629 and 1,337 women with obstetric conditions admitted to one provincial and nine district hospitals in Pattalung Province, Southern Thailand, were evaluated before and after a seminar, respectively. RESULT: The error of coding audit among cases with normal conditions and those with abnormal conditions after the seminar was reduced significantly from 40.7 to 13.0% and from 81.8% to 61.2%, respectively (p < 0.001). A seminar was a significant factor to reduce the errors of summary and coding. In contrast, the incorrect diagnosis summary, abnormal obstetric conditions and the district hospital were significantly associated with the increase of the coding errors. CONCLUSION: The audit and feedback was moderately effective on summary and coding audit but the clinical significance of error reduction in abnormal obstetric conditions was marginal, thus intensive intervention, evaluation, and monitoring are necessary.

Clinical practice guideline for cesarean section due to cephalopelvic disproportion.

OBJECTIVES: To evaluate the effect of the Clinical Practice Guideline (CPG) for cesarean section due to Cephalopelvic Disproportion (CPD) on physician compliance, pregnancy outcomes and cesarean section rate. The study also wants to identify factors associated with physician non-compliance. MATERIAL AND METHOD: 455 medical records of women undergoing a cesarean section due to CPD from January 1, 2002 to December 31, 2003 were reviewed The CPG was implemented on January 1, 2003. The pregnant outcomes of women who delivered from January 1, 2002 to December 31, 2002 were used for comparison. The outcome measurements were physician compliance, pregnancy outcomes and cesarean section rates. Multivariate logistic regression analysis was used to identify factors associated with physician non-compliance. Independent variables included private care, parity, maternal height, Bishop score, maternal age and estimated fetal weight. RESULTS: The compliance rate was 83%. Physician compliance in private practice was lower than in non-private practice (76.6% VS 92.4%). Pregnancy outcomes were not different between the two periods. The cesarean section rates before and after implementation of the CPG were 8.4% and 8.5%, respectively. Private practice, poor Bishop score and estimated fetal weight < or = 3500 g were significant predictors of physician non-compliance. CONCLUSION: The compliance rate was high, but the cesarean section rate due to CPD did not significantly change within a one year period There was no adverse outcome. Physician non-compliance was more common in private practice. Poor Bishop score and high estimated fetal weight were significant predictors.

Socioeconomic factors affecting the accessibility to emergency obstetric care in a periurban area of district Lahore

To find out the frequency of emergencies related to obstetrics and the impact of socioeconomic factors influencing the accessibility to emergency obstetric care. Cross-sectional study. Place and duration of study: Shah di Kohi, District Lahore, Punjab, from October to November 2002.A total of 190 females of reproductive age group who had ever passed through the reproductive process were selected and interviewed. Out of 190 respondents. 55 experienced obstetrical complications. Thus [56%] complications occurred during pregnancy, 30% during delivery and 14% during postnatal period. Complication rate in women who have ever passed through the reproductive process was 8.9% but obstetrical complication rate in last one year [i.e. from30[th] November 2001 to 30[th] November 2002] was 12.5%. The impact of education of respondents and their husbands on accessibility to EOC within half an hour for obstetric emergencies was statistically significant [P- value =0.00058 and 0.00033 respectively] Decision were generally made by husbands, mother in laws and mothers for accessing EOC. In 81% of these complications, the respondents could not have access to EOC with in half an hour [P-value=0.0031]. Respondents' occupation, family income arid availability of conveyance had no effect on accessibility to emergency obstetric care within half an hour for critical obstetric emergencies. Illiteracy among the couples and decision-making by the husbands and mother-in-laws are the main factors responsible for not accessing the EOC within half an hour. Creating awareness among the couples though education and empowerment of women is necessary to decrease the maternal mortality and morbidity