Delays in obstetric care increase the risk of neonatal near-miss morbidity events and death: a case-control study.

BACKGROUND: To evaluate the association between delays in obstetric care and neonatal near-miss mortality events and death in a public maternity referral center. METHODS: This case-control study enrolled 142 neonates, meeting the near-miss criteria of 5-min Apgar < 7, weight < 1500 g, gestational age < 32 weeks, and use of mechanical ventilation or congenital malformation, as well as 284 controls (without the near-miss criteria), at a ratio of 1:2. After follow-up, the following outcomes were reclassified: survival of the neonatal period without the near-miss criteria (true "controls"), "near-miss," and "neonatal death." Maternal sociodemographic characteristics, prenatal care, and pregnancy resolution were evaluated. Pearson's chi-square and Fisher's exact tests were used. Simple logistic regression was performed to determine the association between the three delay factors with near-miss outcomes and/or neonatal death. The variables that had maintained values of p < 0.05 were subjected to multinomial logistic regression. RESULTS: Comparisons revealed the following associations: for controls and near-miss events, delayed access to health services due to a lack of specialized services (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.8-5.1) and inappropriate conduct with the patient (OR, 12.1; 95% CI, 1.3-108.7); for controls and death, absent or inadequate prenatal care (OR, 3.3; 95% CI, 1.6-7.1) and delayed access to health services due to a lack of specialized services (OR, 2.5; 95% CI, 1.1-5.6); and for near-miss events and death, absent or inadequate prenatal care (OR, 2.2; 95% CI, 1.0-5.0). Logistic regression for the combined outcome (near-miss plus neonatal deaths) revealed absent or inadequate prenatal care (OR, 1.9; 95% CI, 1.2-2.8), lack of specialized services (OR, 2.8; 95% CI, 1.7-4.5), and improper conduct with the patient (OR, 10.6; 95% CI, 1.2-91.8). CONCLUSIONS: The delays in obstetric care associated with the presence of near-miss and/or neonatal death included absent or inadequate prenatal care, delayed access to health services due to a lack of specialized services, and inappropriate conduct with the patient.

Associated factors with neonatal near miss in twin pregnancies in a public referral maternity unit in Brazil

Objective: The aim was to analyze the factors associated with neonatal near miss (NNM) in twin pregnancies in a public referral maternity unit in Brazil. Material and Methods: This retrospective, cross-sectional study included 697 twin newborns. Cases of fetal and neonatal deaths were excluded. Neonates were divided into those meeting NNM criteria (5 min Apgar score <7, birth weight <1,500 g, gestational age at delivery <32 weeks, use of mechanical ventilation or congenital malformation, transfer before 28 days of life) and those who did not. In the bivariate analysis, the chi-square and Fisher's exact tests were used. Variables with a p-value ≤0.20 were subjected to the multiple analyses, which followed the Poisson regression model. Results: The cohort consisted of 130 (18.7%) neonates meeting NNM criteria and 567 (81.3%) with no NNM criteria after multiple analyses, the following variables were associated with NNM: no previous pregnancy, prevalence ratio (PR): 1.38 [95% confidence interval (CI), 1.03-1.85]; >3 previous pregnancies, PR: 1.93 (95% CI, 1.38-2.69); premature rupture of membranes, PR: 1.50 (95% CI, 1.70-2.12); intrauterine growth restriction, PR: 2.28 (95% CI, 1.53-3.33); premature labor, PR: 1.63 (95% CI, 1.13-2.35); resuscitation in the delivery room, PR: 1.80 (95% CI, 1.24-2.62); and transfusion of blood products, PR: 4.44 (95% CI, 3.14-6.28). Conclusion: The study findings indicate that having had 0 or >3 previous pregnancies, premature rupture of the membranes, intrauterine growth restriction, resuscitation in the delivery room, premature labor, and transfusion of blood products were associated with NNM in twin pregnancies.

Late umbilical cord clamping does not increase rates of jaundice and the need for phototherapy in pregnancies at normal risk.

Objective: To verify the relationship between the time of clamping of the umbilical cord and the development of neonatal jaundice, the dosage of bilirubin and the need for phototherapy. Methods: Cross-sectional, retrospective study with 398 parturients at normal risk (single term gestation, no complications during gestation or delivery, birth weight between 2500 and 4499 g). The population was divided into three groups regarding the time of cord clamping: <1 min(117, 29.4%), between 1 and 3 min(228, 57.3%) and >3 min(53, 13.3%). Sociodemographic, clinical and obstetric characteristics, birth and delivery data, and maternal and perinatal outcomes were evaluated. Pearson's chi-square test, Fisher's exact test and the Kruskal-Wallis test were used for comparison between the groups. Statistical significance was considered p < .05. Results: The groups were similar in the development of jaundice (p = .370), bilirubin dosage (p = .342) and need for phototherapy (p = .515). Late clamping was more prevalent in vaginal deliveries when compared to cesarean sections (1-3 min: 64 versus 21.4%, >3 min: 16.6 versus 1%) (p < .001). There was no difference in other maternal or perinatal variables. Conclusion: The clamping time of the umbilical cord showed no association with jaundice, bilirubin dosage, or phototherapy needs in neonates at normal risk. The adoption of late clamping was more prevalent in vaginal deliveries.

[The adequacy of the defining characteristics of the diagnostics "impaired gas exange" and spontaneous ventilation" in asmathic children]. / Adecuación de las características definitorias en los diagnósticos de deterioro del intercambio de gases y de la ventilación espontánea en niños asmáticos.

OBJECTIVE: To determine the diagnostic accuracy measures of defining characteristics of respiratory nursing diagnoses "impaired gas exchange" and "impaired spontaneous ventilation" in asmathics children in emergency department. METHODS: Observational, descriptive transversal study developed between April and September 2013 in a hospital in northeastern Brazil with a sample of 205 children. Diagnoses were established by nurses trained experts in this field. Measures of sensitivity, specificity, positive and negative value prediction right positive and negative likelihood ratio and diagnostic odds for the defining characteristics identified were calculated. RESULTS: 28.8% of the evaluated children had "impaired gas exchange". Dyspnea, abnormal breathing, tachycardia and hypoxemia had higher frequencies. Hypoxemia presented as clinical feature high sensitivity and specificity. 5.9% of the evaluated children had "impaired spontaneous ventilation" and their most frequent defining characteristics were dyspnea, increased heart rate and decreased SaO2. The increasing use of accessory muscles to breathe presented the best measures of validity for this diagnosis. CONCLUSION: The hypoxemia and increased use of accessory muscles presented the best measures of the validity respectively to "deterioration in gas exchange" and "impairment of spontaneous ventilation". These characteristics is necessary to provide for adequate definition and use of diagnostics in clinical practice.

Factors associated with neonatal near miss and death in public referral maternity hospitals / Fatores associados ao near miss e óbito neonatais em maternidade pública de referência

Abstract Objectives: to evaluate factors associated with neonatal near miss and death in reference hospitals. Methods: this case-control study included 364 cases and 728 controls among 4,929 births. Cases were identified by Apgar < 7 at 5 minutes, weight < 1500 g, gestational age <32 weeks, mechanical ventilation or congenital malformation. After follow-up, outcomes were reclassified into: true controls, near miss and neonatal death. Hierarchically, variables with a p-value < 0.20 were included in the multiple logistic regression. Results: the neonatal near miss rate was 54.1 per 1,000 live births, and the near-miss-to-death ratio was 2.75. Between the control and near miss groups, the predictor variables were neonatal intensive care admission [OR = 35.6 (16.7 - 75.9)] and central venous access [OR= 74.8 (29.4 - 190.4)]. Between the control and death groups, neonatal intensive care admission [OR = 100.4 (18.8 - 537.0)] and central venous access [OR = 12.7 (3.7 - 43.2)] were significant. Between the near miss and death groups, only Apgar < 7 at 5 minutes [OR = 4.1 (1.6 - 10.6)] and vasoactive drug use [OR = 42.2 (17.1 - 104.5)] were significant. Conclusion: factors associated with a greater chance of near miss and/or neonatal death were: Apgar score <7 at 5 minutes, neonatal intensive care confinement, having central venous access, and use of vasoactive drugs.

Resumo Objetivos: avaliar fatores associados à morbidade "near miss" e óbito neonatal em maternidade pública de referência. Métodos: estudo caso-controle com 4,929 nascimentos encontrou 364 casos e 728 controles. Os casos foram identificados pelos critérios: Apgar< 7 no 5° minuto, peso <1500g, idade gestacional < 32 semanas, ventilação mecânica ou malformação congênita. Reclassificou-sequanto aos desfechos: sobrevivência ao período neonatal sem critérios de near miss ("controles" verdadeiros), "near miss" e "óbito neonatal". Hierarquicamente, as variáveis com p< 0,20 foram incluídas na regressão logística múltipla. Resultados: a taxa de near miss neonatal foi 54,1 por mil nascidos vivos, a razão de near miss e óbito foi 2,75. As variáveis preditoras, entre controles e near miss foi internamento em terapia intensiva neonatal: OR 35,6 (16,7 - 75,9) e acesso venoso central: OR= 74,8 (29,4 -190,4); entre controles e óbito internamento em terapia intensiva neonatal: OR=100,4 (18,8 - 537,0)e acesso venoso central: OR 12,7 (3,7 - 43,2); entre near miss e óbito Apgar no 5°minuto < 7: OR= 4,1 (1,6 - 10,6) e uso de drogas vasoativas: OR= 42,2 (17,1 - 104,5). Conclusão: fatores associados à ocorrência de near miss e/ou óbito neonatal foram: Apgar < 7 no 5° minuto, internamento em terapia intensiva neonatal, acesso venoso central e drogas vasoativas.

Delays in obstetric care increase the risk of neonatal near-miss morbidity events and death: a case-control study

Background: To evaluate the association between delays in obstetric care and neonatal near-miss mortality events and death in a public maternity referral center. Methods: This case-control study enrolled 142 neonates, meeting the near-miss criteria of 5-min Apgar < 7, weight < 1500 g, gestational age < 32 weeks, and use of mechanical ventilation or congenital malformation, as well as 284 controls (without the near-miss criteria), at a ratio of 1:2. After follow-up, the following outcomes were reclassified: survival of the neonatal period without the near-miss criteria (true "controls"), "near-miss," and "neonatal death." Maternal sociodemographic characteristics, prenatal care, and pregnancy resolution were evaluated. Pearson's chi-square and Fisher's exact tests were used. Simple logistic regression was performed to determine the association between the three delay factors with near-miss outcomes and/or neonatal death. The variables that had maintained values of p < 0.05 were subjected to multinomial logistic regression. Results: Comparisons revealed the following associations: for controls and near-miss events, delayed access to health services due to a lack of specialized services (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.8-5.1) and inappropriate conduct with the patient (OR, 12.1; 95% CI, 1.3-108.7); for controls and death, absent or inadequate prenatal care (OR, 3.3; 95% CI, 1.6-7.1) and delayed access to health services due to a lack of specialized services (OR, 2.5; 95% CI, 1.1-5.6); and for near-miss events and death, absent or inadequate prenatal care (OR, 2.2; 95% CI, 1.0-5.0). Logistic regression for the combined outcome (near-miss plus neonatal deaths) revealed absent or inadequate prenatal care (OR, 1.9; 95% CI, 1.2-2.8), lack of specialized services (OR, 2.8; 95% CI, 1.7-4.5), and improper conduct with the patient (OR, 10.6; 95% CI, 1.2-91.8). Conclusions: The delays in obstetric care associated with the presence of near-miss and/or neonatal death included absent or inadequate prenatal care, delayed access to health services due to a lack of specialized services, and inappropriate conduct with the patient. (AU)

Desobstrução ineficaz de vias aéreas: acurácia dos indicadores clínicos em crianças asmáticas / Desobstrucción ineficaz de vías aéreas: exactitud de indicadores clínicos en niños asmáticos / Ineffective airway clearance: accuracy of clinical indicators in asthmatic children

RESUMOObjetivo:analisar as medidas de acurácia dos indicadores clínicos do diagnóstico de enfermagem Desobstrução ineficaz de vias aéreas.Método:estudo transversal, realizado com 205 crianças asmáticas atendidas no setor de emergência de um hospital municipal da cidade de Fortaleza – CE. Utilizou-se roteiro de entrevista e avaliação pulmonar para a coleta de dados.Resultados:o diagnóstico Desobstrução ineficaz de vias aéreas esteve presente em 89,3% da amostra. Os indicadores clínicos mais prevalentes foram dispnéia, mudança na frequência respiratória, mudança no ritmo respiratório, ortopnéia, ruídos adventícios e tosse ineficaz. Os indicadores clínicos de maior sensibilidade foram dispnéia, mudança na frequência respiratória, mudança no ritmo respiratório, ortopnéia e ruídos adventícios respiratórios. Tosse ineficaz e ruídos adventícios respiratórios foram os indicadores com melhor especificidade.Conclusão:o indicador clínico ruídos adventícios respiratórios foi o melhor preditor para desobstrução ineficaz de vias aéreas em crianças asmáticas atendidas em emergência.

RESUMENObjetivo:analizar las medidas de precisión de indicadores clínicos de diagnóstico de enfermería desobstrucción de la vía aérea inefi caz.Método:estudio transversal, con 205 niños asmáticos atendidos en el sector de urgencias de hospital local de Fortaleza-CE, Brasil. Se utilizó guión de entrevista y evaluación pulmonar para recolección de datos.Resultados:el diagnóstico de enfermería desobstrucción de la vía aérea ineficaz estaba presente en 89,3% de la muestra. Los indicadores clínicos más frecuentes fueron disnea, cambio en la frecuencia y ritmo respiratorio, ortopnea, ruidos y tos ineficaz. Los indicadores clínicos de mayor sensibilidad fueron disnea, cambio en la frecuencia y ritmo respiratorio, ortopnea y estertores respiratorios. Tos y estertores respiratorios ineficaces fueron los indicadores con mayor especificidad.Conclusión:el indicador clínico estertores clínicos respiratorios fue el mejor predictor para desobstrucción ineficaz de las vías respiratorias en niños asmáticos atendidos en urgencias.

ABSTRACTObjective:to analyze the accuracy measurements of clinical indicators of the nursing diagnosis Ineffective airway clearance.Method:cross-sectional study with 205 asthmatic children treated in the emergency unit of a hospital in the city of Fortaleza, Ceará. An interview script and pulmonary evaluation were used for data collection.Results:the diagnosis of Ineffective airway clearance was present in 89.3% of the sample. The most prevalent clinical indicators were dyspnea, change in respiratory rate, change in respiratory rhythm, orthopnea, adventitious respiratory sounds and ineffective cough. The clinical indicators with highest sensitivity were dyspnea, change in respiratory rate, change in respiratory rhythm, orthopnea and adventitious respiratory sounds. Ineffective cough and adventitious respiratory sounds were the indicators with best specifi city.Conclusion:the clinical indicator adventitious respiratory sounds was the best predictor of Ineffective airway clearance in asthmatic children treated in emergency units.

Prevalência dos diagnósticos de enfermagem de amamentação no binômio mãe-filho em unidade básica de saúde / Prevalence of nursing diagnoses of breastfeeding in the mother-infant dyad in basic health unit / Prevalencia de diagnósticos de enfermería de lactancia materna en binomio madre-hijo en unidad básica de salud

Estudo transversal, realizado com 28 binômios mãe-filho, usuários de um Centro de Saúde da Família de Fortaleza-CE, Brasil, com o objetivo de identificar os diagnósticos de enfermagem de amamentação, sua frequência de ocorrência, suas características definidoras e o valor da confiança materna com base na escala de autoeficácia em amamentação. Realizou-se a coleta de dados em setembro/outubro de 2010, incluindo entrevista, anamnese e exame físico do binômio. O diagnóstico mais prevalente foi Amamentação eficaz (50%). A escala de autoeficácia em amamentação revelou significância com a presença do diagnóstico Amamentação eficaz e com a ausência de Amamentação interrompida. Embora o diagnóstico Amamentação eficaz tenha uma ocorrência expressiva, evidenciou-se a necessidade de ações efetivas do enfermeiro nesse processo de amamentação.

A cross-sectional study conducted with 28 mother-infant dyads, users of a Family Health Center of Fortaleza-CE, Brazil, that aimed to identify the nursing diagnoses of breastfeeding, their frequency of occurrence, defining characteristics, and the value of maternal confidence based on the breastfeeding self-efficacy scale. Data collection happened during September and October 2010, using interviews, anamnesis, and physical examination of the dyad. The most prevalent diagnosis was Effective breastfeeding (50%). The breastfeeding self-efficacy scale revealed significance in the presence of the nursing diagnosesEffective breastfeeding and the absence of Interrupted breastfeeding. Although the diagnosis Effective breast feeding presented a significant occurrence, we verified the need for effective actions of nurses in the breastfeeding process.

Estudio transversal, con 28 binomios madre-hijo, usuarios de Centro de Salud de la Familia de Fortaleza-CE, Brasil, conobjetivo de identificar los diagnósticos de enfermería de lactancia materna, su frecuencia de ocurrencia, sus características definitorias y el valor de confianza materna basada en la escala de autoeficacia en la lactancia materna. Recogido los datos enseptiembre/octubre de 2010, incluyendo entrevistas, anamnesis y examen físico del binomio. El diagnóstico más frecuente fue de Lactancia materna eficaz (50%). La escala de auto eficacia en lactancia materna fue significativa con la presencia de diagnóstico Lactancia materna eficaz y ausencia de Lactancia materna interrumpida. Aunque el diagnóstico Lactancia materna eficaz tenga incidencia significativa, se ha verificado la necesidad de acciones efectivas del enfermero en el proceso de la lactancia materna.

Adecuación de las características definitorias en los diagnósticos de deterioro del intercambio de gases y de la ventilación espontánea en niños asmáticos / The adequacy of the defining characteristics of the diagnostics "impaired gas exange" and spontaneous ventilation" in asmathic children

OBJETIVO: Determinar la validez de las medidas de las características definitorias de los diagnósticos enfermeros «deterioro del intercambio de gases» y «deterioro de la ventilación espontánea» en niños con asma seguidos en el área de urgencias. MÉTODO: Estudio observacional, descriptivo transversal desarrollado entre abril y septiembre de 2013 en un hospital ubicado en el nordeste de Brasil con una muestra de 205 niños. Los diagnósticos fueron establecidos por enfermeros expertos formados en esta materia. Se calcularon las medidas de sensibilidad, especificidad, valor de predicción positivo y negativo, razón de verosimilitud positiva y negativa y odds ratio diagnóstica para las características definitorias identificadas. RESULTADOS: Un 28,8% de los niños evaluados presentaron «deterioro del intercambio de gases». La disnea, la respiración anormal, la taquicardia y la hipoxemia presentaron las frecuencias más altas. La hipoxemia como característica clínica ha presentado valores altos de sensibilidad y especificidad. Un 5,9% de los niños evaluados presentaron «deterioro de la ventilación espontánea» y sus características definitorias más frecuentes fueron la disnea, el aumento de la frecuencia cardíaca y la disminución de la SaO2. El uso creciente de los músculos accesorios para respirar presentó las mejores medidas de validez para este diagnóstico. CONCLUSIÓN: La hipoxemia y el uso creciente de los músculos accesorios presentaron las mejores medidas de la validez respectivamente para «deterioro del intercambio de gases» y «deterioro de la ventilación espontánea». Es necesario contemplar estas características para una adecuada definición y uso de los diagnósticos en la práctica clínica

OBJECTIVE: To determine the diagnostic accuracy measures of defining characteristics of respiratory nursing diagnoses "impaired gas exchange" and "impaired spontaneous ventilation" in asmathics children in emergency department. METHODS: Observational, descriptive transversal study developed between April and September 2013 in a hospital in northeastern Brazil with a sample of 205 children. Diagnoses were established by nurses trained experts in this field. Measures of sensitivity, specificity, positive and negative value prediction right positive and negative likelihood ratio and diagnostic odds for the defining characteristics identified were calculated. RESULTS: 28.8% of the evaluated children had "impaired gas exchange". Dyspnea, abnormal breathing, tachycardia and hypoxemia had higher frequencies. Hypoxemia presented as clinical feature high sensitivity and specificity.5.9% of the evaluated children had "impaired spontaneous ventilation" and their most frequent defining characteristics were dyspnea, increased heart rate and decreased SaO2. The increasing use of accessory muscles to breathe presented the best measures of validity for this diagnosis. CONCLUSIONS: The hypoxemia and increased use of accessory muscles presented the best measures of the validity respectively to "deterioration in gas exchange" and "impairment of spontaneous ventilation". These characteristics is necessary to provide for adequate definition and use of diagnostics in clinical practice

Medidas de acurácia dos indicadores clínicos dos diagnósticos de enfermagem respiratórios em crianças com asma [manuscrito] / Measures of accuracy of clinical indicators of respiratory nursing diagnoses in children with asthma [manuscript]

O planejamento para direcionar o cuidado e fundamentar o conhecimento de enfermagem em situações clínicas específicas se baseia na utilização de diagnósticos de enfermagem precisos. O uso de bons indicadores clínicos para predizer diagnósticos é fundamental para que se alcance essa precisão. Este estudo teve como objetivo geral determinar as medidas de acurácia dos indicadores clínicos dos diagnósticos de enfermagem respiratórios: Desobstrução ineficaz de vias aéreas, Padrão respiratório ineficaz, Troca de gases prejudicada e Ventilação espontânea prejudicada em crianças asmáticas. Estudo transversal, realizado em um hospital de nível secundário da rede pública de Fortaleza (CE), nos meses de abril a setembro de 2013. A amostra foi composta por 205 crianças. Os dados foram coletados por meio de uma avaliação pulmonar e entrevista com os responsáveis. As informações obtidas foram analisadas para determinar a presença ou ausência dos indicadores clínicos dos diagnósticos em estudo. Posteriormente, esses dados foram encaminhados a enfermeiros diagnosticadores para inferência diagnóstica. Foram utilizados os softwares Excel e SPSS para organização e análise estatística dos dados. O nível de significância adotado foi de 5%. O estudo adotou os princípios éticos e recebeu parecer ético favorável (parecer n°237.389/13). Houve uma discreta prevalência para o sexo masculino (52,3%) e mediana de idade de 36 meses. Das crianças avaliadas, 89,3% desenvolveram Desobstrução ineficaz de vias aéreas; 86,8%, Padrão respiratório ineficaz; 28,8%, Troca de gases prejudicada e 5,9%, Ventilação espontânea prejudicada...

The planning to lead the care and to support the nursing knowledge in specific clinical situations isbased on the use of accurate nursing diagnoses. Theuse of good clinical indicators for predictingdiagnosis is essential in order to reach this precision. This study aimed at determining the measuresofaccuracy of clinical indicators for nursing diagnosis, such as: Ineffective airway clearance, Ineffectivebreathing pattern, Impaired gas exchange and Impaired spontaneous ventilation in asthmatic childrenthrough a cross-sectional study held in a secondarylevel public hospital in Fortaleza (CE), from Aprilto September 2013. The sample consisted of 205 children with asthma whose data were collectedthrough a pulmonary assessment and interviews withtheir parents. The data were analyzed by theresearcher to determine the presence or absence of:Ineffective airway clearance; Ineffective breathingpattern; Impaired gas exchange and Impaired spontaneous ventilation indicators based on a researchprotocol and then diagnostician nurses analyzed this information for diagnostic inference. Forstatistical analysis, SPSS and Excel were used witha significance level of 5 %. The study adopted theethical principles and received the assent of the Federal University of Ceará Ethics and Research(opinion No. 237.389/13)...