Percepção sobre o cuidado à perda gestacional: estudo qualitativo com casais brasileiros / Perceptions on pregnancy loss care: a qualitative study with brazilian couples / Percepción sobre la atención a la pérdida del embarazo: estudio cualitativo con parejas brasileñas

Este artigo analisou a percepção e os sentimentos de casais sobre o atendimento recebido nos serviços de saúde acessados em função de perda gestacional (óbito fetal ante e intraparto). O convite para a pesquisa foi divulgado em mídias sociais (Instagram e Facebook). Dos 66 casais que contataram a equipe, 12 participaram do estudo, cuja coleta de dados ocorreu em 2018. Os casais responderam conjuntamente a uma ficha de dados sociodemográficos e uma entrevista semiestruturada, realizada presencialmente (n=4) ou por videochamada (n=8). Os dados foram gravados em áudio e posteriormente transcritos. A Análise Temática indutiva das entrevistas identificou cinco temas: sentimento de impotência, iatrogenia vivida nos serviços, falta de cuidado em saúde mental, não reconhecimento da perda como evento com consequências emocionais negativas, e características do bom atendimento. Os achados demonstraram situações de violência, comunicação deficitária, desvalorização das perdas precoces, falta de suporte para contato com o bebê falecido e rotinas pouco humanizadas, especialmente durante a internação após a perda. Para aprimorar a assistência às famílias enlutadas, sugere-se qualificação profissional, ampliação da visibilidade do tema entre diferentes atores e reorganização dos serviços, considerando uma diretriz clínica para atenção ao luto perinatal, com destaque para o fortalecimento da inserção de equipes de saúde mental no contexto hospitalar.(AU)

This study analyzed couples' perceptions and feelings about pregnancy loss care (ante and intrapartum fetal death). A research invitation was published on social media (Instagram and Facebook) and data collection took place in 2018. Of the 66 couples who contacted the research team, 12 participated in the study by filling a sociodemographic questionnaire and answering a semi-structured interview in person (n=04) or by video call (n=08). All interviews were audio recorded, transcribed, and examined by Inductive Thematic Analysis, which identified five themes: feelings of impotence, iatrogenic experiences in health services, lack of mental health care, not recognizing pregnancy loss as an emotionally overwhelming event, and aspects of good healthcare. Analysis showed experiences of violence, poor communication, devaluation of early losses, lack of support for contact with the deceased baby, and dehumanizing routines, especially during hospitalization after loss. Professional qualification, extended pregnancy loss visibility among different stakeholders, and reorganization of health services are needed to improve the care offered to grieving families, considering a clinical guideline for perinatal grief care with emphasis on strengthening the insertion of mental health teams in the hospital context.(AU)

Este estudio analizó las percepciones y sentimientos de parejas sobre la atención recibida en los servicios de salud a los que accedieron debido a la pérdida del embarazo (muerte fetal ante e intraparto). La invitación al estudio se publicó en las redes sociales (Instagram y Facebook). De las 66 parejas que se contactaron con el equipo, 12 participaron en el estudio, cuya recolección de datos se realizó en 2018. Las parejas respondieron un formulario de datos sociodemográficos y realizaron una entrevista semiestructurada presencialmente (n=4) o por videollamada (n=08). Los datos se grabaron en audio para su posterior transcripción. El análisis temático inductivo identificó cinco temas: Sentimiento de impotencia, experiencias iatrogénicas en los servicios, falta de atención a la salud mental, falta de reconocimiento de la pérdida como un evento con consecuencias emocionales negativas y características de buena atención. Los hallazgos evidenciaron situaciones de violencia, comunicación deficiente, desvalorización de las pérdidas tempranas, falta de apoyo para el contacto con el bebé fallecido y rutinas poco humanizadas, especialmente durante la hospitalización tras la pérdida. Para mejorar la atención a las familias en duelo, se sugiere capacitación profesional, ampliación de la visibilidad del tema entre los diferentes actores y reorganización de los servicios, teniendo en cuenta una guía clínica para la atención del duelo perinatal, enfocada en fortalecer la inserción de los equipos de salud mental en el contexto hospitalario.(AU)

Clinical audit to enhance safe practice of skilled birth attendants for the fetus with nuchal cord: evidence from a refugee and migrant cohort.

BACKGROUND: Current evidence for optimal management of fetal nuchal cord detected after the head has birthed supports techniques that avoid ligation of the umbilical cord circulation. Routine audit found frequent unsafe management of nuchal cord by skilled birth attendants (SBAs) in migrant and refugee birth centres on the Thai-Burmese border. METHOD: The audit cycle was used to enhance safe practice by SBA for the fetus with nuchal cord. In the three birth centres the action phase of the audit cycle was initially carried out by the doctor responsible for the site. Six months later a registered midwife, present six days per week for three months in one birth facility, encouraged SBAs to facilitate birth with an intact umbilical circulation for nuchal cord. Rates of cord ligation before birth were recorded over a 24 month period (1-July-2011 to 30-June-2013) and in-depth interviews and a knowledge survey of the SBAs took place three months after the registered midwife departure. RESULTS: The proportion of births with nuchal cord ligation declined significantly over the four six monthly quarters from 15.9% (178/1123) before the action phase of the audit cycle; to 11.1% (107/966) during the action phase of the audit cycle with the doctors; to 2.4% (28/1182) with the registered midwife; to 0.9% (9/999) from three to nine months after the departure of the registered midwife, (p < 0.001, linear trend). Significant improvements in safe practice were observed at all three SMRU birth facilities. Knowledge of fetal nuchal cord amongst SBAs was sub-optimal and associated with fear and worry despite improved practice. The support of a registered midwife increased confidence of SBAs. CONCLUSION: The audit cycle and registered midwife interprofessional learning for SBAs led to a significant improvement in safe practice for the fetus with nuchal cord. The authors would encourage this type of learning in organizations with birth facilities on the Thai-Burmese border and in other similar resource limited settings with SBAs.

The impact of vitamin A restriction and ADH1C genotype on marbling in feedlot steers.

A novel SNP was discovered within the promoter region of alcohol dehydrogenase 1C (ADH1C c.-64T>C), the C allele eliminating a potential binding site for the transcription factor C/EPBα. The purpose of this study was to examine if an interaction between this SNP and vitamin A restriction had an effect on carcass characteristics in beef cattle. Following backgrounding on a ß-carotene-deficient diet, 130 steers (50 TT, 50 CT, and 30 CC) were finished for 5 mo and received either no supplemental vitamin A (unsupplemented) or 750,000 IU/mo (supplemented). A subgroup of 5 steers • genotype(-1) • treatment(-1) was randomly selected for pre- and postfinishing liver biopsies to assess vitamin A status and measure gene expression. Unsupplemented steers (Bos taurus) had significantly greater (P < 0.05) marbling scores than supplemented steers. There was a significant interaction between genotype and vitamin A supplementation on ether-extractable intramuscular fat (IMF). Within the unsupplemented treatment, TT steers had nearly 23% greater IMF than CC steers. Additionally, unsupplemented TT steers had over 24% greater IMF than supplemented TT steers. Expression of ADH1C in the liver was additive with each additional T allele, potentially due to the elimination of a possible binding site for C/EBPα. It is plausible that CC cattle have reduced ability to metabolize retinol to retinaldehyde (and subsequently retinoic acid) and that a phenotypic effect is only observed when vitamin A is limiting. Therefore, ADH1C c.-64T>C genotype, in combination with reduced vitamin A supplementation, could potentially be implemented in marker-assisted management to maximize marbling in finishing cattle.

The nuchal cord at birth: what do midwives think and do?

BACKGROUND: No good evidence exists to support the practice of routinely checking for the nuchal cord, yet it is a common medical intervention in birth. Some evidence shows damage to the baby because the practice more frequently leads to premature cord-cutting and the vaginal examination, required by such routine checking, may be physically and/or emotionally damaging to the women. Our objective was to learn what training midwives have received and what their current practice is in relation to a possible nuchal cord at birth? METHOD: Questions about nuchal cord at birth were posted to two online midwifery discussion forums and responses were invited. Twenty-six midwives from 10 countries responded to questions on nuchal cord practices. RESULTS: The teaching and practice of routinely checking for the nuchal cord at birth is widespread, according to at least some participants from all 10 countries. Other midwives from the same countries argued that, although they were aware that the procedure is the dominant midwifery practice, many midwives neither teach it nor perform it routinely. CONCLUSION: In the absence ofclear evidence, firmly entrenched positions are being argued for and against routine checking. The debate is infused with high emotion. Those arguing for routine checking cite safety for the baby as their main concern. Those arguing against checking cite the need to keep birth normal and the well-being of the baby as their primary concerns. There is a need to reconsider how the possibility of nuchal cord at birth should be conceptualised from a midwifery perspective to ensure woman-centred decision-making.

Midwives and the fetal nuchal cord: a survey of practices and perceptions.

A systematic search of studies of intrapartum management of the nuchal umbilical cord at term found no published controlled studies in this area. A postal survey containing both structured and open questions and a request for local protocols and guidelines was sent to all 637 midwives in 7 maternity units in England. There were 401 (63%) responses. There appeared to be no unit guidelines for this area of practice. Midwife approaches to nuchal cord during birth varied, and included clamping and cutting of loose nuchal cords and a hands-off approach to tight nuchal cords. Reasons for specific actions included doing what had been taught during midwifery training and learning from previous personal experiences. Theories of diffusion of innovation and of planned behaviour may provide a conceptual basis for understanding the adoption of specific practices. Future qualitative and controlled studies are needed to explore the nature and consequences of varying approaches to intrapartum nuchal cord management.