The effects of a national policy to reduce c-sections in Brazil.

In this paper, we assess the effects of a national policy implemented in Brazil to avoid unnecessary cesareans. The policy has a supply-side component that prohibits elective c-sections before the 39th gestational week and a demand-side awareness component. Since the policy is not binding for cases with a strong medical c-section indication, we use births of breech- and transverse-positioned babies as a counterfactual for births of cephalic-positioned babies in a difference-in-differences framework. Our results reveal that the policy decreases the rate of c-sections by 1.6 percentage point, and slightly increases gestational time, birthweight, and first-minute APGAR scores. There is evidence that policy effectiveness is driven by its demand-side component.

The dilemma of choosing obstetrics and anesthesia techniques in a patient with cerebral cavernomatosis: a case report.

This report describes the case of a pregnant woman who arrived for preanesthetic assessment of External Cephalic Version (ECV) for fetus in breech presentation and cesarean section in case of ECV failure. Although the technique seems simple, attempts to rotate the fetus can result in elevated intracranial pressure, which might cause malformation bleeding. The most appropriate anesthetic technique in cases of arteriovenous malformations during C-sections has not been determined. Neuroaxial anesthesia is safe only in stable brain cavernomas, but the presence of spinal malformations contraindicates it. Anesthetic goals include stabilizing the blood pressure and reducing the risk of rupture.

Is Vaginal Breech Delivery Still a Safe Option?

OBJECTIVE: To determine whether there was any difference in neonatal and maternal outcomes between breech vaginal delivery and cephalic vaginal delivery. METHODS: A retrospective, case-control study was conducted between January 2015 and December 2017 in a Portuguese hospital. A total of 26 cases of breech vaginal delivery were considered eligible and 52 pregnant women formed the control group. RESULTS: Induced labor was more frequent in the breech vaginal delivery group (46% versus 21%, p = 0.022). Episiotomy was more common in the breech vaginal delivery group (80% versus 52%, p = 0.014), and one woman had a 3rd degree perineal laceration. Newborns in the study group had a lower birthweight (2,805 g versus 3,177 g, p < 0.001). There was no significant difference in the neonatal outcomes. CONCLUSION: The present study showed that breech vaginal delivery at term compared with cephalic presentation was not associated with significant differences in neonatal and maternal morbidity. It also suggests that breech vaginal delivery remains a safe option under strict selection criteria and in the presence of an experienced obstetrician.

OBJETIVO: Avaliar se existem diferenças nos desfechos perinatal e materno entre os partos pélvicos vaginais e eutócicos. MéTODOS: Realizou-se um estudo retrospectivo, caso controle, entre janeiro de 2015 e dezembro de 2017 em um hospital terciário em Portugal. Foram incluídos 26 casos de parto pélvico vaginal e o grupo controle foi formado por 52 grávidas. RESULTADOS: A indução do trabalho de parto ocorreu com mais frequência no grupo do parto pélvico vaginal (46% versus 21%, p = 0.022), bem como a realização de episiotomia (80% versus 52%, p = 0.014). Verificou-se um caso de laceração perineal de 3° grau. Os recém-nascidos do grupo de estudo apresentaram um peso inferior ao nascimento (2.805 g versus 3.177 g, p < 0.001). Em relação aos desfechos perinatais, não se observaram diferenças estatisticamente significativas. CONCLUSãO: O presente estudo mostrou que o parto pélvico vaginal no termo quando comparado com o parto eutócico não se associou a diferenças estatisticamente significativas na morbidade perinatal e materna, e sugere ainda que o parto pélvico vaginal parece ser uma opção segura em casos rigorosamente selecionados e na presença de um obstetra experiente.

Is vaginal breech delivery still a safe option? / Será o parto pélvico vaginal uma opção segura?

Abstract Objective: To determine whether there was any difference in neonatal and maternal outcomes between breech vaginal delivery and cephalic vaginal delivery. Methods: A retrospective, case-control study was conducted between January 2015 and December 2017 in a Portuguese hospital. A total of 26 cases of breech vaginal delivery were considered eligible and 52 pregnant women formed the control group. Results: Induced labor was more frequent in the breech vaginal delivery group (46% versus 21%, p = 0.022). Episiotomy was more common in the breech vaginal delivery group (80% versus 52%, p = 0.014), and one woman had a 3rd degree perineal laceration. Newborns in the study group had a lower birthweight (2,805 g versus 3,177 g, p < 0.001). There was no significant difference in the neonatal outcomes. Conclusion: The present study showed that breech vaginal delivery at term compared with cephalic presentation was not associated with significant differences in neonatal and maternal morbidity. It also suggests that breech vaginal delivery remains a safe option under strict selection criteria and in the presence of an experienced obstetrician.

Resumo Objetivo: Avaliar se existem diferenças nos desfechos perinatal e materno entre os partos pélvicos vaginais e eutócicos. Métodos: Realizou-se um estudo retrospectivo, caso controle, entre janeiro de 2015 e dezembro de 2017 em um hospital terciário em Portugal. Foram incluídos 26 casos de parto pélvico vaginal e o grupo controle foi formado por 52 grávidas. Resultados: A indução do trabalho de parto ocorreu com mais frequência no grupo do parto pélvico vaginal (46% versus 21%, p = 0.022), bem como a realização de episiotomia (80% versus 52%, p = 0.014). Verificou-se um caso de laceração perineal de 3° grau. Os recém-nascidos do grupo de estudo apresentaram um peso inferior ao nascimento (2.805 g versus 3.177 g, p < 0.001). Em relação aos desfechos perinatais, não se observaram diferenças estatisticamente significativas. Conclusão: O presente estudo mostrou que o parto pélvico vaginal no termo quando comparado com o parto eutócico não se associou a diferenças estatisticamente significativas na morbidade perinatal e materna, e sugere ainda que o parto pélvico vaginal parece ser uma opção segura em casos rigorosamente selecionados e na presença de um obstetra experiente.

Assessment of Acute Obstetrical Needs and the Potential Utility of Point-Of-Care Ultrasound in the North East Region of Haiti: A Cross-Sectional Study.

Background: Point-of-care ultrasound (POCUS) implemented through task shifting to nontraditional users has potential as a diagnostic adjuvant to enhance acute obstetrical care in resource-constrained environments with limited access to physician providers. Objective: This study evaluated acute obstetrical needs and the potential role for POCUS programming in the North East region of Haiti. Methods: Data was collected on all women presenting to the obstetrical departments of two Ministry of Public Health and Population (MSPP)-affiliated public hospitals in the North East region of Haiti: Fort Liberté Hospital and Centre Medicosocial de Ouanaminthe. Data was obtained via retrospective review of hospital records from January 1 through March 31, 2016. Trained personnel gathered data on demographics, obstetrical history, diagnoses, clinical care and outcomes using a standardized tool. Diagnoses a priori, defined as those diagnoses whose detection could be assisted with POCUS, included multi-gestations, non-vertex presentation, cephalopelvic disproportion, placental abruption, placenta previa, spontaneous abortions, retained products and ectopic pregnancy. Results: Data were collected from 589 patients during the study period. Median maternal age was 26 years and median gestational age was 38 weeks. The most common reason for seeking care was pelvic pain (85.2%). Sixty-seven (11.5%) women were transferred to other facilities for higher-level care. Among cases not transferred, post-partum hemorrhage, infant mortality and maternal mortality occurred in 2.4%, 3.0% and 0.6% of cases, respectively. There were 69 cases with diagnoses that could have benefited from POCUS use. Between sites, significantly more cases had the potential for improved diagnostics with POCUS at Fort Liberté Hospital (19.8%) than Centre Medicosocial de Ouanaminthe (8.2%) (p < 0.001). Conclusion: Acute obstetrical care is common and POCUS has the potential to impact the care of obstetrical patients in the North East region of Haiti. Future programs evaluating the feasibility of task shifting and the sustainable impacts of acute obstetric POCUS in Haiti will be important.

Breech presentation delivery care: A review of childbirth semiology, mechanism and care / Atención del parto con feto en presentación pelviana: revisión de la semiología, el mecanismo y la atención del parto

RESUMEN Objetivo: revisar los conceptos que subyacen al trabajo de parto con feto en presentación pelviana, su semiología y las maniobras obstétricas que facilitan un resultado materno perinatal exitoso. Materiales y métodos: a partir de un caso hipotético que ambienta de manera práctica el tema, se crea un documento explicativo construido a partir de una revisión narrativa, en donde se examinan los preceptos relacionados con el diagnóstico, el mecanismo del parto en presentación pelviana y el manejo intraparto de la gestante, con énfasis en la adecuada ejecución de las maniobras que facilitan la extracción fetal. Resultados: el parto en presentación pelviana debe ser atendido por vía vaginal cuando se encuentra en periodo expulsivo con encajamiento cumplido. Para su diagnóstico y atención es esencial hacer una adecuada identificación de la presentación, así como conocer su fisiología, la indicación y adecuada ejecución de las maniobras obstétricas que facilitan un parto sin complicaciones. Conclusiones: el mecanismo del parto en presentación pelviana es complejo y requiere, cuando no hay otra alternativa para la atención, que tanto el obstetra como el médico general conozcan su fisiología y las múltiples maniobras obstétricas que facilitan obtener buen resultado materno perinatal.

ABSTRACT Objective: To review the concepts underlying breech presentation delivery as well as the semiology and the obstetric maneuvers contributing to a successful perinatal maternal outcome. Materials and methods: Based on a hypothetical scenario to set the stage for a practical approach to the topic, an explanatory paper built on a narrative review is created in order to examine the principles related to diagnosis, mechanism of delivery and maternal care, emphasizing maneuvers to ease fetal extraction. Results: Breech presentation delivery must be managed through the vaginal canal when already in the expulsion phase with fetal engagement. For diagnosis and care, it is essential to know the unique semiology and physiology of this condition as well as the obstetric maneuvers to facilitate an uncomplicated delivery. Conclusions: The mechanism of childbirth in breech presentation is complex and requires knowledge of its physiology and multiple obstetric maneuvers on the part of the obstetrician as well as the general practitioner, in order to ensure adequate care when there is no other option.

Assistência ao parto e violências sob a ótica de profissionais de saúde / Birth care and violence from the point of view of health professionals

O objetivo deste estudo foi descrever e analisar as representações sociais de profissionais de saúde sobre a assistência ao parto e violências em um hospital universitário do sul do Brasil. Como método foi utilizada a observação participante no interior de um centro obstétrico e entrevistas com profissionais de saúde de um hospital universitário. Adotou-se o referencial socioantropológico das Representações Sociais para a interpretação dos dados. Os resultados mostram que as práticas na atenção ao parto ainda são predominantemente pautadas no modelo de atendimento tecnocrático e no descumprimento dos protocolos estabelecidos no âmbito do Sistema Único de Saúde. Observou-se também que a comunicação conflituosa entre as equipes é uma fonte de tensões que se reflete nas práticas obstétricas. Concluiu -se que é indispensável que ocorram mudanças na formação de profissionais de saúde, com foco nas boas práticas do parto e nascimento, com vistas a implantação do modelo de atenção humanista. (AU)

The aim of this study was to describe and analyze the social representations of health professionals about childbirth care and violence in a university hospital in southern Brazil. The method used was participant observation in an obstetric center, and interviews with health professionals from a university hospital. The socio-anthropological framework of Social Representations was adopted for data interpretation. The results show that childbirth care practices are still predominantly based on the technocratic care model and on non-compliance with the protocols established within the Unified Health System. It was also observed that the conflicting communication between the teams is a source of tensions that are reflected on obstetric practices. It was concluded that changes in the training of health professionals are indispensable, focusing on the good practices of childbirth, with a view to the implementation of the humanistic care model. (AU)

CESAREAN SECTION CLASSIFICATION ACCORDING TO THE ROBSON MODEL, OBSTETRICS UNIT, SAN FELIPE GENERAL HOSPITAL, HONDURAS, APRIL-JUNE, 2017.

OBJECTIVE: To classify cesarean sections according to the Robson Model in the obstetrics unit of an intermediate complexity hospital. METHODS: Descriptive cross-sectional study conducted in the obstetrics unit of the San Felipe General Hospital (HGSF), Tegucigalpa, Honduras, between April and June 2017. Out of 477 clinical records of patients undergoing elective and/ or emergency surgery during the study period, 89 were selected using probabilistic random selection. A descriptive analysis of sociodemographic variables, clinical/obstetric indications, and categories of the Robson model was conducted. Authorization from the institution was obtained. RESULTS: The proportion of cesarean sections during the study period was 59.8% (477/797; 95% CI:56.3-63.3). Of the cases studied, 48/89 (53.9%) were classified as "no risk pregnancy" (categories 1-4); the most frequent indications in this group were low fetal reserve in 22/48 (22/48*100%) and cephalopelvic disproportion in 16/48 (16/48*100%). In the "risk group" (categories 5-10), in 41/89 (46.1%), indications were cephalopelvic disproportion and breech presentation, (8/41) (8/41*100%), respectively. The main contributors to cesarean section were groups 1 (17/89; 19.1%), 2 (20/89, 22.5%) and 5 (20/89; 22.5%), for a total of 64.1%. CONCLUSIONS: The Robson model is applicable in our setting and the classification provides information that can be used as a diagnostic and surveillance tool for cesarean sections in a level II institution.

TITULO: CLASIFICACIÓN DE CESÁREAS SEGÚN EL MODELO DE ROBSON, UNIDAD OBSTÉTRICA, HOSPITAL GENERAL SAN FELIPE, HONDURAS, ABRIL-JUNIO DE 2017. OBJETIVO: Clasificar las cesáreas según el modelo de Robson en la unidad obstétrica de un hospital de nivel medio de complejidad. METODOS: Estudio descriptivo, transversal, llevado a cabo en unidad obstétrica del HGSF, Tegucigalpa, Honduras, entre abril y junio de 2017. Se seleccionan 89 de 477 historias clínicas de pacientes sometidas a cesárea electiva o de emergencia en el periodo del estudio mediante selección aleatoria probabilística. Se realiza análisis descriptivo de variables sociodemográficas, indicaciones clínicas/obstétricas y categorías del modelo de Robson. Se obtuvo autorización institucional. RESULTADOS: La proporción de cesáreas en el periodo fue 59,8 % (477/797; IC 95 %:56,3-63,3). Se clasificaron 48/89 (53,9%) cesáreas estudiadas como embarazo "sin riesgo" (categorías 1-4); la indicación más frecuente en este grupo fue baja reserva fetal 22/48 (22/48*100 %) y desproporción céfalo-pélvica 16/48 (16/48*100 %). En el grupo "de riesgo" (categorías 5-10) en 41/89 (46,1 %) las indicaciones fueron desproporción céfalo-pélvica y presentación pélvica (8/41) (8/41*100 %) respectivamente. Los principales aportantes de cesárea fueron los grupos 1 (17/89; 19,1 %), 2 (20/89, 22,5 %) y 5 (20/89; 22,5 %) para totalizar 64,1 %. CONCLUSIONES: El modelo de Robson es aplicable en nuestro medio y la clasificación aporta información como herramienta de diagnóstico y vigilancia en la realización de cesáreas en una institución de segundo nivel.

Breech presentation delivery care: A review of childbirth semiology, mechanism and care / Atención del parto con feto en presentación pelviana: revisión de la semiología, el mecanismo y la atención del parto

Objective: To review the concepts underlying breech presentation delivery as well as the semiology and the obstetric maneuvers contributing to a successful perinatal maternal outcome. Materials and methods: Based on a hypothetical scenario to set the stage for a practical approach to the topic, an explanatory paper built on a narrative review is created in order to examine the principles related to diagnosis, mechanism of delivery and maternal care, emphasizing maneuvers to ease fetal extraction. Results: Breech presentation delivery must be managed through the vaginal canal when already in the expulsion phase with fetal engagement. For diagnosis and care, it is essential to know the unique semiology and physiology of this condition as well as the obstetric maneuvers to facilitate an uncomplicated delivery. Results: The mechanism of childbirth in breech presentation is complex and requires knowledge of its physiology and multiple obstetric maneuvers on the part of the obstetrician as well as the general practitioner, in order to ensure adequate care when there is no other option.

TITULO: ATENCIÓN DEL PARTO CON FETO EN PRESENTACIÓN PELVIANA: REVISIÓN DE LA SEMIOLOGÍA, EL MECANISMO Y LA ATENCIÓN DEL PARTO. Objetivo: Revisar los conceptos que subyacen al trabajo de parto con feto en presentación pelviana, su semiología y las maniobras obstétricas que facilitan un resultado materno perinatal exitoso. Materiales y métodos: A partir de un caso hipotético que ambienta de manera práctica el tema, se crea un documento explicativo construido a partir de una revisión narrativa, en donde se examinan los preceptos relacionados con el diagnóstico, el mecanismo del parto en presentación pelviana y el manejo intraparto de la gestante, con énfasis en la adecuada ejecución de las maniobras que facilitan la extracción fetal. Resultados: El parto en presentación pelviana debe ser atendido por vía vaginal cuando se encuentra en periodo expulsivo con encajamiento cumplido. Para su diagnóstico y atención es esencial hacer una adecuada identificación de la presentación, así como conocer su fisiología, la indicación y adecuada ejecución de las maniobras obstétricas que facilitan un parto sin complicaciones. Resultados: El mecanismo del parto en presentación pelviana es complejo y requiere, cuando no hay otra alternativa para la atención, que tanto el obstetra como el médico general conozcan su fisiología y las múltiples maniobras obstétricas que facilitan obtener buen resultado materno perinatal.

Applying the newman-peacock prognostic system to a portuguese obstetrical population - A useful tool? / Utilização do modelo de prognóstico Newman-Peacock numa população obstétrica portuguesa - uma ferramenta útil?

Abstract Background External cephalic version (ECV) is a maneuver that enables the rotation of the non-cephalic fetus to a cephalic presentation. The Newman-Peacock (NP) index, which was proposed by Newman et al. in a study published in 1993, was described as a prediction tool of the success of this procedure; it was validated in a North-American population, and three prognostic groups were identified. Purpose To evaluate the value of the NP score for the prediction of a successful ECV in a Portuguese obstetrical population, and to evaluate maternal and fetal safety. Methods We present an observational study conducted from 1997-2016 with pregnant women at 36-38 weeks of pregnancy who were candidates for external cephalic version in our department. Demographic and obstetrical data were collected, including the parameters included in the NP index (parity, cervical dilatation, estimated fetal weight, placental location and fetal station). The calculation of the NP score was performed, and the percentages of success were compared among the three prognostic groups and with the original study by Newman et al. The performance of the score was determined using the Student t-test, the Chi-squared test, and a receiver operating characteristic (ROC) curve. Results In total, 337 women were included. The overall success rate was of 43.6%. The univariate analysis revealed that multiparity, posterior placentation and a less engaged fetus were factors that favored a successful maneuver (p < 0.05). Moreover, a higher amniotic fluid index was also a relevant predictive factor (p < 0.05). The Newman-Peacock score had a poorer performance in our population compared with that of the sample of the original study, but we still found a positive relationship between higher scores and higher prediction of success (p < 0.001). No fetal or maternal morbidities were registered. Conclusions The Newman-Peacock score had a poorer performance among our population compared to its performance in the original study, but the results suggest that this score is still a useful tool to guide our clinical practice and counsel the candidate regarding ECV.

Resumo Âmbito A versão cefálica externa (VCE) é uma manobra que permite a obtenção de uma apresentação cefálica em fetos não-cefálicos. O índice de Newman-Peacock (NP), proposto por Newman et al em um estudo publicado em 1993, foi descrito como preditivo do sucesso desta manobra; ele foi validado numa população norte-americana, e três grupos de prognóstico diferentes foram identificados. Objectivo Avaliação do valor preditivo do índice de NP para o sucesso da VCE numa população obstétrica portuguesa, bem como da segurança materno-fetal. Métodos Foi realizado no nosso departamento umestudo observacional entre 1997- 2016 em grávidas candidatas a VCE entre as 36 e as 38 semanas de gravidez. Foram colhidos dados demográficos e obstétricos, incluindo os parâmetros incluídos no índice de NP (a paridade, a dilatação cervical, a estimativa do peso fetal, a localização placentária e a altura da apresentação fetal). A pontuação das candidatas de acordo como índice de NP e a percentagemde sucesso da VCE foramcomparadas entre os três grupos de prognóstico, e também com o estudo original de Newman et al. O desempenho deste índice foi avaliado recorrendo aos testes t de Student, qui-quadrado e curva receiver operating characteristic (ROC). Resultados Foram incluídas 337 mulheres. A taxa de sucesso da manobra foi de 43,6%. A análise univariada mostrou que a multiparidade, a placentação posterior e uma apresentação não encravada foram favoráveis para o sucesso do procedimento (p < 0,05). Adicionalmente, um maior índice de líquido amniótico revelou-se também como um fator preditivo significativo (p < 0,05). O índice de Newman-Peacock apresentou um desempenho inferior na nossa população comparativamente à sua descrição original, porém continuou a verificar-se uma relação positiva entre pontuações mais elevadas e uma maior percentagem de sucesso (p < 0,001). Conclusão No nosso trabalho, o índice de Newman-Peacock apresentou um valor preditivo inferior comparativamente ao estudo original, porém os resultados mostram que se mantém uma ferramenta com utilidade para a prática clínica e para o aconselhamento das candidatas a versão cefálica externa.

Applying the Newman-Peacock Prognostic System to a Portuguese Obstetrical Population - A Useful Tool?

BACKGROUND: External cephalic version (ECV) is a maneuver that enables the rotation of the non-cephalic fetus to a cephalic presentation. The Newman-Peacock (NP) index, which was proposed by Newman et al. in a study published in 1993, was described as a prediction tool of the success of this procedure; it was validated in a North-American population, and three prognostic groups were identified. PURPOSE: To evaluate the value of the NP score for the prediction of a successful ECV in a Portuguese obstetrical population, and to evaluate maternal and fetal safety. METHODS: We present an observational study conducted from 1997-2016 with pregnant women at 36-38 weeks of pregnancy who were candidates for external cephalic version in our department. Demographic and obstetrical data were collected, including the parameters included in the NP index (parity, cervical dilatation, estimated fetal weight, placental location and fetal station). The calculation of the NP score was performed, and the percentages of success were compared among the three prognostic groups and with the original study by Newman et al. The performance of the score was determined using the Student t-test, the Chi-squared test, and a receiver operating characteristic (ROC) curve. RESULTS: In total, 337 women were included. The overall success rate was of 43.6%. The univariate analysis revealed that multiparity, posterior placentation and a less engaged fetus were factors that favored a successful maneuver (p < 0.05). Moreover, a higher amniotic fluid index was also a relevant predictive factor (p < 0.05). The Newman-Peacock score had a poorer performance in our population compared with that of the sample of the original study, but we still found a positive relationship between higher scores and higher prediction of success (p < 0.001). No fetal or maternal morbidities were registered. CONCLUSIONS: The Newman-Peacock score had a poorer performance among our population compared to its performance in the original study, but the results suggest that this score is still a useful tool to guide our clinical practice and counsel the candidate regarding ECV.

ÂMBITO: A versão cefálica externa (VCE) é uma manobra que permite a obtenção de uma apresentação cefálica em fetos não-cefálicos. O índice de Newman-Peacock (NP), proposto por Newman et al em um estudo publicado em 1993, foi descrito como preditivo do sucesso desta manobra; ele foi validado numa população norte-americana, e três grupos de prognóstico diferentes foram identificados. OBJECTIVO: Avaliação do valor preditivo do índice de NP para o sucesso da VCE numa população obstétrica portuguesa, bem como da segurança materno-fetal. MéTODOS: Foi realizado no nosso departamento um estudo observacional entre 1997­2016 em grávidas candidatas a VCE entre as 36 e as 38 semanas de gravidez. Foram colhidos dados demográficos e obstétricos, incluindo os parâmetros incluídos no índice de NP (a paridade, a dilatação cervical, a estimativa do peso fetal, a localização placentária e a altura da apresentação fetal). A pontuação das candidatas de acordo com o índice de NP e a percentagem de sucesso da VCE foram comparadas entre os três grupos de prognóstico, e também com o estudo original de Newman et al. O desempenho deste índice foi avaliado recorrendo aos testes t de Student, qui-quadrado e curva receiver operating characteristic (ROC). RESULTADOS: Foram incluídas 337 mulheres. A taxa de sucesso da manobra foi de 43,6%. A análise univariada mostrou que a multiparidade, a placentação posterior e uma apresentação não encravada foram favoráveis para o sucesso do procedimento (p < 0,05). Adicionalmente, um maior índice de líquido amniótico revelou-se também como um fator preditivo significativo (p < 0,05). O índice de Newman-Peacock apresentou um desempenho inferior na nossa população comparativamente à sua descrição original, porém continuou a verificar-se uma relação positiva entre pontuações mais elevadas e uma maior percentagem de sucesso (p < 0,001). CONCLUSãO: No nosso trabalho, o índice de Newman-Peacock apresentou um valor preditivo inferior comparativamente ao estudo original, porém os resultados mostram que se mantém uma ferramenta com utilidade para a prática clínica e para o aconselhamento das candidatas a versão cefálica externa.

Ultrasound Examination for Infants Born Breech by Elective Cesarean Section With a Normal Hip Exam for Instability.

INTRODUCTION: Because of the risk of developmental dysplasia of the hip in infants born breech-despite a normal physical exam-the American Academy of Pediatrics (AAP) guidelines recommend ultrasound (US) hip imaging at 6 weeks of age for breech females and optional imaging for breech males. The purpose of this study is to report US results and follow-up of infants born breech with a normal physical exam. METHODS: The electronic medical record for children born at 1 hospital from 2008 to 2011 was reviewed. Data were analyzed for sex, birth weight, breech position, birth order, ethnicity, US and x-ray results, follow-up, and cost. RESULTS: A total of 237 infants were born breech with a normal physical examination, all delivered by cesarean section. Of the infants, 55% were male and 45% female. About 151 breech infants (64%) with a normal Barlow and Ortolani exam had a precautionary hip US as recommended by the AAP performed at an average of 7 weeks of age. Eighty-six breech infants (35%) did not have an US and were followed clinically. Of the 151 infants that had an US, 140 (93%) were read as normal. None had a dislocated hip. Two patients had a normal physical exam but laxity on US. These 2 patients were the only infants treated in a Pavlik harness. A pediatric orthopaedic surgeon followed those with subtle US findings and no laxity until normal. CONCLUSIONS: The decision by the AAP to recommend US screening at 6 weeks of age for infants with a normal physical exam but breech position was based on an extensive literature review and expert opinion. Not all pediatricians are following the AAP guidelines. The decision to perform an US should be done on a case-by-case basis by the examining physician. A more practical, cost-effective strategy would be to skip the US if the physical exam is normal and simply obtain an AP pelvis x-ray at 4 months. LEVEL OF EVIDENCE: Level III-this is a case-control study investigating the outcomes of infants on data drawn from the electronic medical record.

What Is the Impact of Center Variability in a Multicenter International Prospective Observational Study on Developmental Dysplasia of the Hip?

BACKGROUND: Little information exists concerning the variability of presentation and differences in treatment methods for developmental dysplasia of the hip (DDH) in children < 18 months. The inherent advantages of prospective multicenter studies are well documented, but data from different centers may differ in terms of important variables such as patient demographics, diagnoses, and treatment or management decisions. The purpose of this study was to determine whether there is a difference in baseline data among the nine centers in five countries affiliated with the International Hip Dysplasia Institute to establish the need to consider the center as a key variable in multicenter studies. QUESTIONS/PURPOSES: (1) How do patient demographics differ across participating centers at presentation? (2) How do patient diagnoses (severity and laterality) differ across centers? (3) How do initial treatment approaches differ across participating centers? METHODS: A multicenter prospective hip dysplasia study database was analyzed from 2010 to April 2015. Patients younger than 6 months of age at diagnosis were included if at least one hip was completely dislocated, whereas patients between 6 and 18 months of age at diagnosis were included with any form of DDH. Participating centers (academic, urban, tertiary care hospitals) span five countries across three continents. Baseline data (patient demographics, diagnosis, swaddling history, baseline International Hip Dysplasia Institute classification, and initial treatment) were compared among all nine centers. A total of 496 patients were enrolled with site enrolment ranging from 10 to 117. The proportion of eligible patients who were enrolled and followed at the nine participating centers was 98%. Patient enrollment rates were similar across all sites, and data collection/completeness for relevant variables at initial presentation was comparable. RESULTS: In total, 83% of all patients were female (410 of 496), and the median age at presentation was 2.2 months (range, 0-18 months). Breech presentation occurred more often in younger (< 6 months) than in older (6-18 months at diagnosis) patients (30% [96 of 318] versus 9% [15 of 161]; odds ratio [OR], 4.2; 95% confidence interval [CI], 2.3-7.5; p < 0.001). The Australia site was underrepresented in breech presentation in comparison to the other centers (8% [five of 66] versus 23% [111 of 479]; OR, 0.3, 95% CI, 0.1-0.7; p = 0.034). The largest diagnostic category was < 6 months, dislocated reducible (51% [253 of 496 patients]); however, the Australia and Boston sites had more irreducible dislocations compared with the other sites (ORs, 2.1 and 1.9; 95% CIs, 1.2-3.6 and 1.1-3.4; p = 0.02 and 0.015, respectively). Bilaterality was seen less often in older compared with younger patients (8% [seven of 93] versus 26% [85 of 328]; p < 0.001). The most common diagnostic group was Grade 3 (by International Hip Dysplasia Institute classification), which included 58% (51 of 88) of all classified dislocated hips. Splintage was the primary initial treatment of choice at 80% (395 of 496), but was far more likely in younger compared with older patients (94% [309 of 328] versus 18% [17 of 93]; p < 0.001). CONCLUSIONS: With the lack of strong prognostic indicators for DDH identified to date, the center is an important variable to include as a potential predictor of treatment success or failure.

[External cephalic version]. / Versión cefálica externa.

Objetives: To analyze the rate of successful external cephalic versions in our center and caesarean sections that would be avoided with the use of external cephalic versions. Material and methods: From January 2012 to March 2016 external cephalic versions carried out at our center, which were a total of 52. We collected data about female age, gestational age at the time of the external cephalic version, maternal body mass index (BMI), fetal variety and situation, fetal weight, parity, location of the placenta, amniotic fluid index (ILA), tocolysis, analgesia, and newborn weight at birth, minor adverse effects (dizziness, hypotension and maternal pain) and major adverse effects (tachycardia, bradycardia, decelerations and emergency cesarean section). Results: 45% of the versions were unsuccessful and 55% were successful. The percentage of successful vaginal delivery in versions was 84% (4% were instrumental) and 15% of caesarean sections. With respect to the variables studied, only significant differences in birth weight were found; suggesting that birth weight it is related to the outcome of external cephalic version. Probably we did not find significant differences due to the number of patients studied. Conclusion: For women with breech presentation, we recommend external cephalic version before the expectant management or performing a cesarean section. The external cephalic version increases the proportion of fetuses in cephalic presentation and also decreases the rate of caesarean sections.

Is there a predilection for breech infants to demonstrate spontaneous stabilization of DDH instability?

BACKGROUND: Breech position subjects the fetal hip to abnormal mechanical forces. However, unlike genetic or tissue factors linked to developmental dysplasia of the hip (DDH), the causative effect of the breech position ends when the infant is born. The purpose of this study was to evaluate the rate of spontaneous stabilization in mildly unstable hips of breech-presenting infants compared with similarly lax hips in infants with a genetic or tissue-related cause of DDH. METHODS: We studied a consecutive series of infants presenting to our institution at 8 weeks of age or younger with DDH from January 2008 to January 2012. Infants with increased hip laxity on dynamic ultrasound examination but without frank instability on clinical provocation maneuvers and no history of prior treatment were evaluated. The endpoint was spontaneous stabilization of ultrasound-detected instability, or intervention due to persistent instability on follow-up dynamic ultrasound. A logistic regression model using backward likelihood ratio method was used to analyze predictors of spontaneous stabilization. RESULTS: We identified 122 hips in 79 infants with instability on dynamic ultrasound evaluation but with stable clinical examinations. Spontaneous stabilization of sonographic instability occurred in 90 hips (74%) at a mean age of 9 weeks (range, 4 to 18 wk). Breech hips more frequently spontaneously stabilized compared with nonbreech hips (80% vs. 66%). Regression analysis determined that breech presentation was a strong independent predictor for spontaneous hip stabilization (odds ratio, 3.72; 95% confidence interval, 1.45-9.60; P=0.006). Sex, family history, intrauterine positioning syndromes, side involved, bilateralism, and grade of sonographic hip instability were not independently predictive of spontaneous hip stabilization. CONCLUSIONS: DDH infants with a history of breech presentation are 3.72 times more likely to experience spontaneous resolution of mild hip instability compared with nonbreech infants. Awareness that breech presentation is a strong independent predictor of spontaneous laxity resolution can guide parental counseling and early care of DDH. LEVEL OF EVIDENCE: Level II, prognostic retrospective study.