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BACKGROUND: Brazil has one of the highest prevalence of cesarean sections in the world. The private health system is responsible for carrying out most of these surgical procedures. A quality improvement project called Adequate Childbirth Project ("Projeto Parto Adequado"- PPA) was developed to identify models of care for labor and childbirth, which place value on vaginal birth and reduce the frequency of cesarean sections without a clinical indication. This research aims to evaluate the implementation of PPA in private hospitals in Brazil. METHOD: Evaluative hospital-based survey, carried out in 2017, in 12 private hospitals, including 4,322 women. We used a Bayesian network strategy to develop a theoretical model for implementation analysis. We estimated and compared the degree of implementation of two major driving components of PPA-"Participation of women" and "Reorganization of care" - among the 12 hospitals and according to type of hospital (belonging to a health insurance company or not). To assess whether the degree of implementation was correlated with the rate of vaginal birth data we used the Bayesian Network and compared the difference between the group "Exposed to the PPA model of care" and the group "Standard of care model". RESULTS: PPA had a low degree of implementation in both components "Reorganization of Care" (0.17 - 0.32) and "Participation of Women" (0.21 - 0.34). The combined implementation score was 0.39-0.64 and was higher in hospitals that belonged to a health insurance company. The vaginal birth rate was higher in hospitals with a higher degree of implementation of PPA. CONCLUSION: The degree of implementation of PPA was low, which reflects the difficulties in changing childbirth care practices. Nevertheless, PPA increased vaginal birth rates in private hospitals with higher implementation scores. PPA is an ongoing quality improvement project and these results demonstrate the need for changes in the involvement of women and the care offered by the provider.
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Cesárea , Hospitales Privados , Mejoramiento de la Calidad , Humanos , Femenino , Cesárea/estadística & datos numéricos , Cesárea/normas , Hospitales Privados/normas , Hospitales Privados/estadística & datos numéricos , Embarazo , Brasil , Adulto , Teorema de BayesRESUMEN
Introducción: La tasa de cesáreas es importante para cualquier centro de atención hospitalaria. Es un indicador de calidad utilizado en muchas publicaciones y, aunque no es una estadística vital, se ha reconocido como un indicador de la calidad de atención. Objetivo: Conocer la tasa de cesáreas en una institución utilizando los grupos de Robson. Métodos: Estudio retrospectivo de bases de datos de la maternidad. Se consideraron las variables de paridad, cesárea anterior, trabajo de parto, inducción, para poder clasificar la población según los grupos de Robson. El análisis consideró los nacimientos desde octubre del 2014 hasta junio del 2021. Resultados: Se observó una tasa de 27,9% en el periodo de estudio. El grupo 5 de Robson, que considera pacientes con una o más tasa de cesáreas, mostró una elevada tasa (68%), contribuyó con el 36% de todas las cesáreas, siendo solamente el 15% de la población. El grupo 3, de multíparas con trabajo de parto espontáneo, tuvo una tasa del 1,8%, contribuyó al 0,4% de las cesáreas, siendo el 20% de la población de estudio. Se encontró una correlación significativa entre uso de parto instrumental y menor tasa de cesáreas, al realizar análisis por operador (Spearman rho: -0,45; IC95%: -0,788 a -0,0190; p = 0,043). Conclusión: La tasa de cesáreas observada fue 27,9%, y las pacientes con cesárea anterior son un grupo donde pueden concentrarse mayores esfuerzos para bajar la tasa global. Entre los operadores, los usuarios de parto instrumental tuvieron menor proporción cesáreas.
Introduction: The cesarean section rate is important for any hospital care center. It is a quality indicator used in many publications, and although not a vital statistic, it has been recognized as an indicator of the quality of care. Objective:: To know the cesarean section rate in an institution using Robson groups. Methods: Retrospective study of maternity databases. The variables of parity, previous cesarean section, labor, induction was considered in order to classify the population according to Robson groups. The analysis considered births from October 2014 to June 2021. Results: A rate of 27.9% was observed in the study period. Robson's group 5, which considers patients with one or more rate of cesarean sections, showed a high rate (68%), contributing to 36% of all cesarean sections, being only 15% of the population. Group 3, multiparas with spontaneous labor, had a rate of 1.8%, contributing to 0.4% of cesarean sections, making up 20% of the study population. A significant correlation was found between the use of instrumental delivery and a lower rate of cesarean sections, when analyzing by operator (Spearman rho: -0.45; IC95%: -0.788 to -0.0190; p = 0.043). Conclusion: The observed cesarean section rate was 27.9%, and patients with a previous cesarean section are a group where greater efforts can be concentrated to lower the overall rate. Among the operators, users of instrumental delivery had a lower proportion of cesarean sections.
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Humanos , Femenino , Embarazo , Cesárea/normas , Parto Obstétrico/métodos , Cesárea/estadística & datos numéricosAsunto(s)
Humanos , Femenino , Embarazo , Cesárea/efectos adversos , Cesárea/normas , Atención Prenatal , Servicios de Salud Materno-Infantil , COVID-19 , Partería , ObstetriciaRESUMEN
OBJECTIVE: To identify procedures to reduce maternal morbidity during cesarean. MATERIAL AND METHODS: The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. RESULTS: Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds. CONCLUSION: In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.
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Cesárea , Obstetricia , Femenino , Humanos , Recién Nacido , Embarazo , Antieméticos , Cesárea/efectos adversos , Cesárea/métodos , Cesárea/normas , Ginecólogos , Hipotermia/etiología , Hipotermia/prevención & control , Obesidad , Obstetras , Sobrepeso , Oxitocina , Francia , Obstetricia/normasRESUMEN
The decision-to-delivery interval is a widely used term at non-elective caesarean section. While the definition may appear self-evident, there is no universally agreed consensus about when this period begins and ends. We reviewed the literature for original research utilising the terms 'decision-to-delivery', 'decision-to-incision' or 'incision-to-delivery' and examined definitions used for decision, delivery, incision, as well as any additional time intervals that were assessed. Our analysis demonstrated an inconsistent non-standardised approach to defining these intervals, which might have clinical practice and medicolegal ramifications. We propose that the decision-to-delivery interval should be defined as follows: the interval between the time at which the senior obstetrician makes the decision that a caesarean section is required and the time at which the fetus (or first fetus in the case of multiples) is delivered. The decision time should ideally be recorded contemporaneously in the medical notes or partogram.
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Cesárea/normas , Toma de Decisiones , Femenino , Humanos , Embarazo , Factores de TiempoRESUMEN
BACKGROUND: The National guidelines of most developed countries suggest a target of 30 minutes of the decision to delivery interval for emergency cesarean section. Such guidelines may not be feasible in poorly resourced countries and busy obstetric settings. It is generally accepted that the decision to delivery interval should be kept to the minimum time achievable to prevent adverse outcomes. Therefore, this study aimed to determine the average decision to delivery interval and its effect on perinatal outcomes in emergency cesarean section. METHODS: A prospective cohort study was conducted from May to July 2020 at Bahir Dar City Public Hospitals. A total of 182 participants were enrolled, and data were collected using a structured and pre-tested questionnaire. A systematic sampling technique was applied to select the study subjects. Data were cleaned and entered into Epi-Data version 4.6 and exported to SPSS version 25 software for analysis. Logistic regression analysis was performed to identify predictors of outcome variables, and variables with a p-value of <0.05 were considered statistically significant. RESULTS: The average decision to delivery interval was 43.73 ±10.55 minutes. Anesthesia time [AOR = 2.1, 95%CI = (1.3-8.4)], and category of emergency cesarean section [AOR = 3, 95% CI = (2.1-11.5)] were predictors of decision to delivery interval. The prolonged decision to delivery interval had a statistically significant association with composite adverse perinatal outcomes (odds ratio [OR] = 1.8, 95% confidence interval [CI] = (1.2-6.5). CONCLUSION: The average decision to delivery interval was longer than the recommended time. It should always be considered an important factor contributing to perinatal outcomes. Therefore, to prevent neonatal morbidity and mortality, a time-dependent action is needed.
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Cesárea/normas , Parto Obstétrico/normas , Parto/fisiología , Resultado del Embarazo , Adulto , Cesárea/efectos adversos , Estudios Transversales , Etiopía/epidemiología , Femenino , Hospitales Públicos , Humanos , Embarazo , Factores de TiempoRESUMEN
OBJECTIVES: This article suggests a unified way to perform Cesarean sections. Even in the same departments, different modifications are in use. Therefore, one cannot rely on the early or late outcome of the procedure as long as all the surgical steps are not standardized. METHODS: The Misgav Ladach (Stark) Cesarean Section presented here is an evidence-based operation. Its basic principles are a modified Joel-Cohen abdominal incision, one-layer continuous suturing of the uterus using a big needle, leaving peritoneum open, closing fascia continuously and a few Donati skin sutures. RESULTS: This method has been subjected to scores of comparative studies with other methods in use, proving its advantages over them concerning duration, blood loss, febrile morbidity, need for analgesics, and costs. CONCLUSIONS: It is suggested that this method should be used as the standardized universal method which will enable comparison between obstetricians and institutions, and offer the parturient the best possible outcome.
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Cesárea/métodos , Cesárea/normas , Medicina Basada en la Evidencia , Femenino , Humanos , Evaluación de Resultado en la Atención de Salud , EmbarazoRESUMEN
OBJECTIVES: Uterine closure technique in caesarean section (CS) influences the rate of late complications in subsequent pregnancies. As no common recommendation on suture techniques exists, we developed a questionnaire to determine the techniques currently used and the frequencies of late complications. METHODS: The online questionnaire consisted of 13 questions and was sent to 648 obstetric hospitals (level I-IV) in Germany. Number of CS, rate of vaginal birth after caesarean section (VBAC), the type of uterus suturing technique and the frequency of uterine dehiscences, ruptures and placenta accreta spectrum (PAS) were queried. The answers were anonymous, and results were evaluated descriptively. RESULTS: The response rate was 24.7%. The mean CS rate was 27.3% (±6.2), the repeat CS rate 33.2% (±18.1). After CS, 46.2% (±20.2) women delivered vaginally. To close the uterotomy, 74.4% of hospitals used single layer continuous sutures, 16.3% single layer locked sutures, 3.8% interrupted sutures, 3.1% double layer continuous sutures and 2.5% used other suture techniques. The percentages of observed uterine dehiscences did not differ significantly between the different levels of care nor did the uterotomy suture techniques. CONCLUSIONS: There is no uniform suturing technique in Germany. A detailed description of suture technique in surgery reports is required to evaluate complications in subsequent pregnancies. National online surveys on obstetric topics are feasible and facilitate the discussion on the need to define a standardized uterine closure technique for CS.
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Cesárea/métodos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Técnicas de Sutura/estadística & datos numéricos , Útero/cirugía , Cesárea/normas , Cesárea/estadística & datos numéricos , Femenino , Alemania , Hospitales , Humanos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Pautas de la Práctica en Medicina/normas , Embarazo , Estudios Retrospectivos , Encuestas y Cuestionarios , Técnicas de Sutura/normas , Resultado del TratamientoRESUMEN
OBJECTIVES: One of the most common indications for intrapartum cesarean delivery (CD) is nonreassuring fetal heart rate (NRFHR) patterns. We aimed to study the long-term effect of CD due to NRFHR on the risk for subsequent childhood infectious morbidity-related hospitalizations of the offspring. STUDY DESIGN: A population-based cohort study was performed, comparing total and different subtypes of infectious morbidity-related pediatric hospitalizations among offspring born by CD due to NRFHR versus labor dystocia (failure of labor to progress during the 1st or 2nd stage). The analysis included all singletons born between the years 1999-2014 at a single tertiary regional medical center. Infectious-related morbidities included hospitalizations involving a predefined set of International Classification of Diseases, 9th revision codes, as recorded in hospital computerized files. Infants with congenital malformations, multiple gestations, vaginal deliveries and vacuum failure were excluded from the analysis. Perinatal mortality cases were excluded from the long-term analysis. A Kaplan-Meier survival curve was used to compare the cumulative morbidity, and a Cox proportional hazards model was constructed to adjust for confounders. RESULTS: The study population included 9956 newborns who met inclusion criteria; among them, 5810 (58%) were born by CD due to NRFHR, and 4146 (42%) were born via CD following labor dystocia with normal fetal heart rate (comparison group). Offspring born following NRFHR had higher rates of infectious morbidity-related hospitalizations (11.4% vs. 9.1%; odds ratio, 1.3; 95% confidence interval, 1.1-1.5; P < 0.01; Kaplan-Meier survival curve P < 0.01). The association remained significant and independent while adjusting for gestational age, maternal age and comorbidities, using a Cox proportional hazards model (adjusted hazard ratio, 1.3; 95% confidence interval, 1.2-1.4; P < 0.01). CONCLUSIONS: In our population, CD due to NRFHR is a risk factor for pediatric infectious morbidity-related hospitalizations of the offspring.
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Cesárea/estadística & datos numéricos , Frecuencia Cardíaca Fetal , Efectos Tardíos de la Exposición Prenatal/prevención & control , Adulto , Cesárea/normas , Femenino , Edad Gestacional , Humanos , Recién Nacido , Morbilidad , Embarazo , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Centros de Atención Terciaria/estadística & datos numéricos , Adulto JovenRESUMEN
OBJECTIVE: To determine maternal and neonatal outcomes among women undergoing second stage emergent cesarean delivery (ECD) versus vacuum-assisted delivery (VAD) of low birthweight neonates. MATERIALS AND METHODS: A retrospective cohort study from two tertiary medical centers. We included women who underwent either ECD or VAD during the second stage of labor, and delivered neonates with a birthweight of <2500 g during 2011-2019. Characteristics and outcomes were compared between the groups. The primary outcome was the rate of a composite adverse neonatal outcome, defined as the presence of ≥1 of the following: Apgar 5 min < 7, respiratory distress syndrome, neonatal intensive care unit admission, mechanical ventilation and intrapartum fetal death. RESULTS: The study cohort included 611 patients, of whom 46 had ECD and 565 had VAD. Baseline characteristics did not differ between the groups. The rate of Apgar score < 7 at 1 min was higher among the ECD group]10 (22%) vs. 29 (5%), OR (95% CI) 5.1 (2.3-11.3), p < 0.001[. Other neonatal and maternal outcomes were similar in both groups. CONCLUSIONS: Neonatal and maternal outcomes do not differ substantially between ECD and VAD of neonates weighing <2500 g. This information may be useful when contemplating the preferred mode of delivery in this setting.
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Cesárea/normas , Recién Nacido de Bajo Peso , Factores de Tiempo , Extracción Obstétrica por Aspiración/normas , Adulto , Cesárea/estadística & datos numéricos , Femenino , Humanos , Recién Nacido , Segundo Periodo del Trabajo de Parto/fisiología , Embarazo , Estudios Retrospectivos , Extracción Obstétrica por Aspiración/estadística & datos numéricosRESUMEN
INTRODUCTION: The cesarean section rate around the world, currently estimated at 21.1%, continues to increase. Women who undergo a cesarean section sustain a seven- to ten-fold greater risk of infective morbidity compared with those who deliver vaginally. MATERIAL AND METHODS: We aimed to assess the impact of changing gloves intraoperatively on post-cesarean section infective morbidity (PROSPERO CRD42018110529). MEDLINE, Scopus, Web of Science, CINAHL, WHO Global Index Medicus, and Cochrane Central were searched for randomized controlled trials until June 2020. Published randomized controlled trials that evaluated the effects of glove changing during cesarean section on infective complications were considered eligible for the review. Two reviewers independently selected studies, assessed the risk of bias, and extracted data about interventions and adverse maternal outcomes. Dichotomous variables were presented and included in the meta-analyses as risk ratios (RR) with 95% confidence intervals (CI). The quality of evidence was assessed using the GRADE approach in alignment with the recommendations from the Cochrane Review Group. RESULTS: We identified seven randomized controlled trials reporting data over 1948 women. Changing gloves during a cesarean section was associated with a statistically significantly lower incidence of wound infective complications (RR 0.41, 95% CI 0.26-0.65, p < 0.0001; GRADE moderate quality evidence). This intervention seemed to be effective only if performed after delivery of the placenta. No significant difference was seen in the incidence of endometritis (RR 0.96, 95% CI 0.78-1.20, p = 0.74; GRADE moderate quality evidence) and/or febrile morbidity (RR 0.73, 95% CI 0.30-1.81, p = 0.50; GRADE moderate quality evidence), regardless of the timing of the intervention. CONCLUSIONS: Changing gloves after delivery of the placenta during a cesarean section is associated with a significant reduction in the incidence of post-surgical wound complications compared with keeping the same gloves throughout the whole surgery. However, an adequately powered study to assess the limitations and cost-effectiveness of the intervention is needed before this recommendation can be translated into current clinical practice.
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Cesárea/normas , Guantes Quirúrgicos , Infección de la Herida Quirúrgica/prevención & control , Femenino , Humanos , Complicaciones Posoperatorias/prevención & control , EmbarazoRESUMEN
OBJECTIVES: In Germany, cesarean section (CS) rates more than doubled within the past two decades. For analysis, auditing and inter-hospital comparison, the 10-Group Classification System (TGCS) is recommended. We used the TGCS to analyze CS rates in two German hospitals of different levels of care. METHODS: From October 2017 to September 2018, data were prospectively collected. Unit A is a level three university hospital, unit B a level one district hospital. The German birth registry was used for comparison with national data. We performed two-sample Z tests and bootstrapping to compare aggregated (unit A + B) with national data and unit A with unit B. RESULTS: In both datasets (national data and aggregated data unit A + B), Robson group (RG) 5 was the largest contributor to the overall CS rate. Compared to national data, group sizes in RG 1 and 3 were significantly smaller in the units under investigation, RG 8 and 10 significantly larger. Total CS rates between the two units differed (40.7 vs. 28.4%, p<0.001). The CS rate in RG 5 and RG 10 was different (p<0.01 for both). The most relative frequent RG in both units consisted of group 5, followed by group 10 and 2a. CONCLUSIONS: The analysis allowed us to explain different CS rates with differences in the study population and with differences in the clinical practice. These results serve as a starting point for audits, inter-hospital comparisons and for interventions aiming to reduce CS rates.
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Cesárea/estadística & datos numéricos , Hospitales de Distrito/estadística & datos numéricos , Hospitales Universitarios/estadística & datos numéricos , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Adulto , Benchmarking , Cesárea/normas , Auditoría Clínica , Femenino , Alemania , Disparidades en el Estado de Salud , Disparidades en Atención de Salud/estadística & datos numéricos , Hospitales de Distrito/normas , Hospitales Universitarios/normas , Humanos , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/estadística & datos numéricos , Embarazo , Estudios ProspectivosRESUMEN
BACKGROUND: Emergency cesarean section is a commonly performed surgical procedure in pregnant women with life-threatening conditions of the mother and/or fetus. According to the Royal College of Obstetricians and Gynecologists and the American College of Obstetricians and Gynecologists, decision to delivery interval for emergency cesarean sections should be within 30 min. It is an indicator of quality of care in maternity service, and if prolonged, it constitutes a third-degree delay. This study aimed to assess the decision to delivery interval and associated factors for emergency cesarean section in Bahir Dar City Public Hospitals, Ethiopia. METHOD: An institution-based cross-sectional study was conducted at Bahir Dar City Public Hospitals from February to May 2020. Study participants were selected using a systematic random sampling technique. A combination of observations and interviews was used to collect the data. Data entry and analysis were performed using Epi-data version 3.1 and SPSS version 25, respectively. Statistical significance was set at p < 0.05. RESULT: Decision-to-delivery interval below 30 min was observed in 20.3% [95% CI = 15.90-24.70%] of emergency cesarean section. The results showed that referral status [AOR = 2.5, 95% CI = 1.26-5.00], time of day of emergency cesarean section [AOR = 2.5, 95%CI = 1.26-4.92], status of surgeons [AOR = 2.95, 95%CI = 1.30-6.70], type of anesthesia [AOR = 4, 95% CI = 1.60-10.00] and transfer time [AOR = 5.26, 95% CI = 2.65-10.46] were factors significantly associated with the decision to delivery interval. CONCLUSION: Decision-to-delivery intervals were not achieved within the recommended time interval. Therefore, to address institutional delays in emergency cesarean section, providers and facilities should be better prepared in advance and ready for rapid emergency action.
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Cesárea/estadística & datos numéricos , Toma de Decisiones Clínicas , Tratamiento de Urgencia/estadística & datos numéricos , Complicaciones del Trabajo de Parto/cirugía , Atención Perinatal/estadística & datos numéricos , Adulto , Cesárea/normas , Estudios Transversales , Tratamiento de Urgencia/normas , Etiopía/epidemiología , Femenino , Adhesión a Directriz/estadística & datos numéricos , Hospitales Públicos/normas , Hospitales Públicos/estadística & datos numéricos , Hospitales Urbanos/normas , Hospitales Urbanos/estadística & datos numéricos , Humanos , Recién Nacido , Muerte Materna/prevención & control , Complicaciones del Trabajo de Parto/diagnóstico , Complicaciones del Trabajo de Parto/mortalidad , Atención Perinatal/normas , Muerte Perinatal/prevención & control , Guías de Práctica Clínica como Asunto , Embarazo , Calidad de la Atención de Salud/normas , Factores de Tiempo , Tiempo de Tratamiento/estadística & datos numéricos , Adulto JovenRESUMEN
Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. We present two different techniques of laparoscopic management of CSP, with the concomitant repair of the coexisting uterine isthmocele. The first case is a combination of diagnostic hysteroscopy and laparoscopic extraction of conception products, and the second technique is a combination of laparoscopy and guided Dilation & Curettage. We also conducted a thorough review of the literature to present all cases of laparoscopic treatment of CSP, focusing on the surgical technique, the operation outcome, and the future pregnancies. Laparoscopy is a potential effective treatment of CSP.
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Cesárea/efectos adversos , Cicatriz/cirugía , Laparoscopía/métodos , Adulto , Cesárea/métodos , Cesárea/normas , Cicatriz/etiología , Femenino , Procedimientos Quirúrgicos Ginecológicos/métodos , Procedimientos Quirúrgicos Ginecológicos/estadística & datos numéricos , Humanos , Laparoscopía/estadística & datos numéricos , Embarazo , Complicaciones del Embarazo/etiología , Complicaciones del Embarazo/cirugíaRESUMEN
OBJECTIVE: To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates. DESIGN: Multicentre stepped-wedge cluster design. SETTING: Sixteen maternity units located in four regions across England, Scotland and Wales. POPULATION: Women with singleton live births between October 2016 and March 2018. METHODS: Stepwise region by region roll-out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi-level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case-mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth). MAIN OUTCOME MEASURES: Obstetric anal sphincter injury in singleton live vaginal births. RESULTS: A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26-34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65-0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period. CONCLUSIONS: The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth. TWEETABLE ABSTRACT: OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use.
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Parto Obstétrico/normas , Laceraciones/epidemiología , Complicaciones del Trabajo de Parto/epidemiología , Mejoramiento de la Calidad/estadística & datos numéricos , Adulto , Canal Anal/lesiones , Cesárea/efectos adversos , Cesárea/normas , Cesárea/estadística & datos numéricos , Análisis por Conglomerados , Parto Obstétrico/efectos adversos , Parto Obstétrico/estadística & datos numéricos , Inglaterra/epidemiología , Episiotomía/efectos adversos , Episiotomía/normas , Episiotomía/estadística & datos numéricos , Femenino , Humanos , Laceraciones/prevención & control , Modelos Logísticos , Complicaciones del Trabajo de Parto/prevención & control , Perineo/lesiones , Embarazo , Proyectos de Investigación , Factores de Riesgo , Escocia/epidemiología , Gales/epidemiologíaRESUMEN
ABSTRACT: Brazil has a high rate of cesarean sections (CS) that cannot be solely justified by women's clinical conditions; thus, other causes, for example, CS on maternal request and physicians' fear of litigation as possible influencing factors, cannot be overlooked.This study aimed to identify through a survey whether Brazilian gynecologists and obstetricians (GOs) perform defensive CS.In this cross-sectional, descriptive study, a questionnaire was administered. The target population comprised of GOs who were members of premier Brazilian professional associations of gynecology and obstetrics. A total of 403 GOs participated in the survey using an obstetrics questionnaire about litigation and defensive medicine (DM). Statistical analyses were performed on pairs of variables to determine the risk factors of performing CS due to concerns of complications during vaginal delivery and to avoid lawsuits.The mean age of the GOs was 47.7âyears who were mostly female (58.3%) and having worked professionally in both public and private sectors (71.7%). Of all participants, 80.6% had been sued or knew an obstetrician who had been sued. The obstetricians who had been sued or who knew a colleague that had been sued exhibited a significantly higher likelihood of performing defensive CS than physicians who had not been sued or did not know physicians who had been sued. The perception of a higher risk of lawsuits against obstetricians influenced the practice of DM and led to a more than six-fold increase in CSs in specialists with this perception compared to specialists who did not believe the presence of an increased risk of litigation in obstetrics existed.The majority of Brazilian GOs perform defensive CS. It is important to consider DM as one of the causes of high CS rates in Brazil and include it in the development of public policies to reduce these CS rates.
Asunto(s)
Cesárea/estadística & datos numéricos , Medicina Defensiva/métodos , Adulto , Actitud del Personal de Salud , Brasil , Cesárea/normas , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pautas de la Práctica en Medicina/estadística & datos numéricos , Embarazo , Encuestas y CuestionariosRESUMEN
BACKGROUND: Numerous studies have identified a relationship between nurse staffing and adverse patient outcomes in medical / surgical patient populations. However, little is known about the impact of labor and delivery (L&D) nurse staffing and adverse birth outcomes, such as unintended cesarean delivery, in low-risk term-gestation women. PURPOSE: We examined nurse staffing patterns on the likelihood of cesarean sections (C-sections) among low- risk, full gestation births and provided a testing framework to distinguish optimal from ineffective levels of nurse staffing. METHODS: This retrospective descriptive study used hours of productive nursing time per delivery as the treatment variable to determine direct nursing time per delivery and its impact on the likelihood of a C-section. For comparisons, we also assessed the likelihood of augmentations and of inductions, as well as the number of neonatal intensive care unit (NICU) hours per birth. We limited our sample to those births between 37 and 42 weeks of gestation. Two complimentary models (the quadratic and piecewise regressions) distinguishing optimal staffing patterns from ineffective staffing patterns were developed. The study was implemented in eleven hospitals that are part of a large, integrated healthcare system in the Southwest. DISCUSSION: While a simple linear regression of the likelihood of a C-section on nursing hours per delivery indicated no statistically distinguishable effect, our 'optimal staffing' model indicated that nurse staffing hours employed by using a large sample of hospitals were actually minimizing C-sections (robustness checks are provided using similar model comparisons for the likelihood of augmentation and induction, and NICU hours). Where the optimal staffing models did not appear to be effective for augmentations, inductions, and NICU hours, we found significant differences between facilities (i.e., significant fixed effects for hospitals). In all specifications, we also controlled for weeks of gestation, race, sex of the child, and mother's age.
Asunto(s)
Cesárea/enfermería , Enfermeras y Enfermeros/provisión & distribución , Admisión y Programación de Personal/normas , Carga de Trabajo/normas , Adulto , Cesárea/normas , Cesárea/tendencias , Femenino , Humanos , Recién Nacido , Enfermeras y Enfermeros/estadística & datos numéricos , Enfermería Obstétrica/métodos , Enfermería Obstétrica/normas , Enfermería Obstétrica/tendencias , Admisión y Programación de Personal/estadística & datos numéricos , Embarazo , Calidad de la Atención de Salud/normas , Calidad de la Atención de Salud/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Carga de Trabajo/psicología , Carga de Trabajo/estadística & datos numéricosRESUMEN
BACKGROUND: Unexplained clinical variation is a major issue in planned birth i.e. induction of labour and planned caesarean section. AIM: To map attitudes and knowledge of maternity care professionals regarding indications for planned birth, and assess inter-professional (midwifery versus medical) and intra-professional variation. METHODS: A custom-created survey of medical and midwifery staff at eight Sydney hospitals. Staff were asked to rate their level of agreement with 45 "evidence-based" statements regarding caesareans and inductions on a five-point Likert scale. Responses were grouped by profession, and comparisons made of inter- and intra-professional responses. FINDINGS: Total 275 respondents, 78% midwifery and 21% medical. Considerable inter- and intra-professional variation was noted, with midwives generally less likely to consider any of the planned birth indications "valid" compared to medical staff. Indications for induction with most variation in midwifery responses included maternal characteristics (age≥40, obesity, ethnicity) and fetal macrosomia; and for medical personnel in-vitro fertilisation, maternal request, and routine induction at 39 weeks gestation. Indications for caesarean with most variation in midwifery responses included previous lower segment caesarean section, previous shoulder dystocia, and uncomplicated breech; and for medical personnel uncomplicated dichorionic twins. Indications with most inter-professional variation were induction at 41+ weeks versus 42+ weeks and cesarean for previous lower segment caesarean section. DISCUSSION: Both inter- and intra-professional variation in what were considered valid indications reflected inconsistency in underlying evidence and/or guidelines. CONCLUSION: Greater focus on interdisciplinary education and consensus, as well as on shared decision-making with women, may be helpful in resolving these tensions.
Asunto(s)
Actitud del Personal de Salud , Cesárea/normas , Parto Obstétrico/psicología , Parto Obstétrico/normas , Enfermeras Obstetrices/psicología , Adulto , Cesárea/efectos adversos , Cesárea/estadística & datos numéricos , Parto Obstétrico/estadística & datos numéricos , Femenino , Edad Gestacional , Humanos , Trabajo de Parto Inducido , Trabajo de Parto/fisiología , Masculino , Servicios de Salud Materna , Persona de Mediana Edad , Partería , Embarazo , Complicaciones del Embarazo , Encuestas y CuestionariosRESUMEN
The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.
Asunto(s)
Anestesia Obstétrica/normas , Cesárea/normas , Recuperación Mejorada Después de la Cirugía/normas , Cesárea/efectos adversos , Consenso , Femenino , Humanos , Complicaciones Posoperatorias/etiología , Embarazo , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Racial disparities in maternal morbidity and mortality remain a pressing public health problem. Variations in cesarean section (C-section) rates among racial and ethnic groups have been well documented, though reasons for these variations remain unknown. In the Department of Veterans Affairs (VA), nearly half of all women Veterans are of reproductive age and >40% of these women are racial and ethnic minorities. Because the VA does not provide obstetrical services, all obstetrical care is provided by community obstetrical providers under the auspices of the VA Community Care Network. However, little is known regarding the rates and correlates of C-sections among women Veterans receiving community obstetrical care. OBJECTIVE: To examine predictors of C-section deliveries among a cohort of racially diverse pregnant Veterans enrolled in VA care at 15 VA medical facilities nationwide. RESEARCH DESIGN: Cross-sectional analysis of a longitudinal, prospective, multisite, observational cohort study of pregnant, and postpartum Veterans receiving community-based obstetrical care. RESULTS: Overall, 659 Veterans delivered babies during the study period, and 35% of the deliveries were C-sections. Predictors of C-section receipt included being a woman of color [adjusted odds ratio (AOR), 1.76; 95% confidence interval (CI), 1.19-2.60], having an Edinburgh Postnatal Depression Scale score ≥10 (AOR, 1.71; 95% CI, 1.11-2.65), having a higher body mass indexes (AOR, 1.07; 95% CI, 1.04-1.11), and women who were older (AOR, 1.08; 95% CI, 1.03-1.13). There was a substantial racial variation in C-section rates across our 15 study sites, with C-section rates meeting or exceeding 50% for WOC in 8 study sites. CONCLUSIONS: There is substantial racial and geographic variation in C-section rates among pregnant Veterans receiving obstetrical care through VA community care providers. Future research should carefully examine variations in C-sections by the hospital, and which providers and hospitals are included in VA contracts. There should also be an increased focus on the types of providers women Veterans have access to for obstetrical care paid for by the VA and the quality of care delivered by those providers.