Maternal and neonatal effects of epidural levobupivacaine combined with fentanyl or sufentanil for elective cesarean-section in brachycephalic breeds.

The aim of this study was to compare the safety and clinical efficacy of epidural levobupivacaine combined with fentanyl or sufentanil for bitches undergoing elective cesarean-section and the impact of these anesthetic protocols on neonatal viability. The anesthetic protocol consisted of intramuscular morphine (0.2 mg/kg), followed by an intravenous bolus of propofol, in a dose sufficient to allowed the puncture of the lumbosacral space. The dogs were randomly allocated to receive 0.5 % levobupivacaine plus fentanyl (2.5 µg/kg; LF: n = 9) or sufentanil (1 µg/kg; LS; n = 11). Maternal cardiorespiratory parameters were monitored at specific time points during surgery. Intraoperative propofol supplementation was based on the presence of head and/or thoracic limb movements. Neonatal reflex responses and the Apgar score (range 0-10 points) were assessed at 5 and 60 minutes after birth. Puppy mortality rate was recorded until 24 hours after birth. Data were analyzed using two-way ANOVA, Tukey's test, Wilcoxon signed rank test, and Fisher's exact test (P < 0.05). Intraoperatively, maternal cardiorespiratory variables and propofol requirements were similar between groups, with no detection of anesthetic complications. The puppy reflex responses did not differ between groups at any time point. The medians (range) of Apgar scores were lower (P = 0.016) in the LF [5 (1-9)] at 5 minutes in comparison with LS [6 (2-9)], while no intergroup differences were recorded at 60 minutes [LF = 8 (2-10); LS = 9 (6-10]. The total mortality rate was 4.1 %. In the LS group, no puppies died, while in the LF 8 % of the puppies died in the first 24 hours after birth (P = 0.11). Epidural levobupivacaine combined with fentanyl or sufentanil provided minimal maternal and neonatal adverse effects, but neither protocol enabled the performance of a C-section in 100 % of the French and English bulldogs, without propofol supplementation.

Caesarean delivery on maternal request: the perspective of the postpartum women.

BACKGROUND: Caesarean delivery on maternal request (CDMR) is an increasing delivery option among women. As such, we aimed to understand the reasons that led pregnant women to request a caesarean delivery. METHODS: A phenomenological study was conducted with semi-structured interviews, in a convenience sample, for women who had undergone a CDMR between March and June 2023, in a public reference university hospital in Campinas, Brazil. The interviews were recorded, transcribed and subjected to thematic analysis, supported by Nvivo®, and Reshape®. RESULTS: We interviewed eighteen women between 21 and 43 years of age. The reasons for C-section as their choice were: 1) fear of labour pain, 2) fear for safety due to maternal or fetal risks, 3) traumatic previous birth experiences of the patient, family or friends 4) sense of control, and 5) lack of knowledge about the risks and benefits of C-section. CONCLUSIONS: The perception of C-section as the painless and safest way to give birth, the movement of giving voice and respecting the autonomy of pregnant women, as well as the national regulation, contribute to the increased rates of surgical abdominal delivery under request. Cultural change concerning childbirth and better counseling could support a more adequate informed decision-making about delivery mode.

Effect of the implementation of an enhanced recovery after surgery protocol (ERAS) in patients undergoing an elective cesarean section.

OBJECTIVES: To demonstrate that the application of an enhanced recovery after surgery (ERAS) protocol in elective cesarean sections is associated with reduced hospital stay without increasing maternal complications. MATERIAL AND METHODS: This retrospective, comparative study included patients who underwent an elective cesarean section. The patients were divided into groups: group 1, women who received elements of standardized care according to ERAS guidelines, and group 2, women who did not receive this care. RESULTS: The study included 295 patients, 139 in group 1 (ERAS) and 156 in group 2. The demographic characteristics were similar. Hospital stay and postoperative pain at 24 and 48 hours were lower in patients in group 1; these differences were statistically significant (p < 0.001). The overall complication rate, head pain, surgical wound infection, urinary retention, and readmission were similar in both groups. CONCLUSIONS: The application of an ERAS protocol can reduce hospital stay and postoperative pain without increasing the postoperative complication rate in patients who undergo an elective cesarean section. In developing countries, the application of this protocol could help in optimizing available health system resources.

Viability of ex-vivo myography as a diagnostic tool for rectus abdominis muscle electrical activity collected at Cesarean section within a diamater cohort study.

BACKGROUND: Ex-vivo myography enables the assessment of muscle electrical activity response. This study explored the viability of determining the physiological responses in muscles without tendon, as rectus abdominis muscle (RAM), through ex-vivo myography to assess its potential as a diagnostic tool. RESULTS: All tested RAM samples (five different samples) show patterns of electrical activity. A positive response was observed in 100% of the programmed stimulation. RAM 3 showed greater weight (0.47 g), length (1.66 cm), and width (0.77 cm) compared to RAM 1, RAM 2, RAM 4 and RAM 5 with more sustained electrical activity over time, a higher percentage of fatigue was analyzed at half the time of the electrical activity. The order of electrical activity (Mn) was RAM 3 > RAM 5 > RAM 1 > RAM 4 > RAM 2. No electrical activity was recorded in the Sham group. CONCLUSIONS: This study shows that it is feasible to assess the physiological responses of striated muscle without tendon as RAM, obtained at C-section, under ex vivo myography. These results could be recorded, properly analyzed, and demonstrated its potential as a diagnostic tool for rectus abdominis muscle electrical activity.

Uso de eritromicina como procinético para cesárea con cuatro horas de ayuno / Use of erythromycin as a prokinetic for cesarean section with four hours of fasting

Resumen: El ayuno preoperatorio es fundamental como requisito previo a la mayoría de cirugías tanto para las electivas como para las urgencias relativas. Sin embargo, no siempre se cumplen las condiciones idóneas al momento de abordar a un paciente y la falta de ayuno es una condición que puede poner en riesgo la vida del mismo, siendo un factor de riesgo mayúsculo para la broncoaspiración del contenido gástrico. Hasta el momento se cuenta con un reducido arsenal farmacológico de medicamentos que con distinta función e intensidad aceleran el vaciamiento gástrico; la eritromicina no se encuentra en esta lista de manera oficial. A pesar de que ya ha sido utilizada ampliamente con este fin en el ámbito de los procedimientos endoscópicos, no existen aún suficientes reportes en los que se haya puesto a prueba su eficacia procinética en cirugía de urgencia, específicamente una cesárea. Este artículo, además de ofrecer un breve sumario de dicho macrólido, presenta el caso de una paciente embarazada con ingesta alimenticia reciente, en la cual se obtuvieron las condiciones idóneas para cirugía tan sólo cuatro horas después de la administración de la eritromicina.

Abstract: Preoperative fasting is essential as a prerequisite for most surgeries, either elective procedures or relative emergencies. However, the ideal conditions for surgery are not always fulfilled at the time of approaching a patient, and the lack of fasting is a factor that could endanger patient's life, being a major risk factor for bronchoaspiration of gastric content. Until now there is a small pharmacological list of medications that with different function and intensity accelerate gastric emptying, erythromycin is not officially on this list. Despite the fact that it has already been widely used for this purpose in the field of endoscopic procedures, there are not enough reports about its efficacy in emergency surgery, specifically C-section. This article, in addition to offering a brief summary of this macrolide, presents a case in which after erythromycin administration to a pregnant patient with a recent food intake, the ideal conditions for surgery were obtained only four hours later.

Colostrum IgA1 antibodies recognize antigens from Helicobacter pylori and prevent cytoskeletal changesin human epithelial cells.

Helicobacter pylori is a Gram-negative bacterium found on the luminal surface of the gastric mucosa in at least 50% of the world's human population. The protective effect of breastfeeding against H. pylori infection has been extensively reported; however, the mechanisms behind this protection remain poorly understood. Human IgA from colostrum has reactivity against H. pylori antigens. Despite that IgA1 and IgA2 display structural and functional differences, their reactivity against H. pylori had not been previously determined. We attested titers and reactivity of human colostrum-IgA subclasses by ELISA, immunoblot, and flow cytometry. Colostrum samples from healthy mothers had higher titers of IgA; and IgA1 mostly recognized H. pylori antigens. Moreover, we found a correlation between IgA1 reactivity and their neutralizing effect determined by inhibition of cytoskeletal changes in AGS cells infected with H. pylori. In conclusion, colostrum-IgA reduces H. pylori infection of epithelial gastric cells, suggesting an important role in preventing the bacteria establishment during the first months of life. As a whole, these results suggest that IgA1 from human colostrum provides protection that may help in the development of the mucosal immune system of newborn children.

Presencia de infección de sitio quirúrgico en procedimientos gineco-obstétricos en un hospital de II nivel de atención, Honduras 2017-2018 / Presence of surgical site infection in obstetric-gynecological procedures in a level II care hospital, Honduras 2017-2018

OBJETIVO: Identificar la presencia de infección de sitio quirúrgico y factores de riesgo en pacientes sometidas a cirugías Gineco-Obstétricas de forma programada o de urgencia en un hospital de II nivel de atención en Honduras. METODOLOGÍA: Estudio observacional, descriptivo, retrospectivo; recopilando 226 fichas del registro de infección de sitio quirúrgico recuperadas de los expedientes clínicos brindados por el servicio de estadística del Hospital Mario Catarino Rivas. Captando pacientes sometidas a cirugías Gineco-Obstétricas, durante el 2017 y 2018. RESULTADOS: 99 fichas cumplieron los criterios de inclusión, reportando una edad de 24 años [RIQ, 19,0 - 30,0], peso 82,0 kg [RIQ, 51,7 - 98,25], talla 154 cm [150,0 - 158,0] y el IMC de 25,8 ± 3,6 kg/m2. Un 9,1% presento antecedentes de inmunosupresión. 5,1% presento ISQ. El 55.6% de las cirugías se realizó el mismo día de ingreso del paciente. El tiempo entre la profilaxis antibiótica y el comienzo de la intervención quirúrgica es de 60 minutos [RIQ, 40,0 - 160,0]. La duración de los procedimientos quirúrgicos son de 45 minutos [RIQ, 35,0 - 55,0]. Los microrganismos aislados en los cultivos fueron Cocos gram positivos (2/5), Enterococcus faecalis (1/5), Klebsiella pneumoniae (2/5). CONCLUSIÓN: La presencia de ISQ en cirugías Gineco-Obstétricas del HMCR es del 5.1%, identificando los siguientes factores de riesgo: edad extrema, obesidad, diabetes mellitus, estado inmunitario (VIH), profilaxis antibiótica (temprana); por último, la técnica y el tiempo quirúrgico.

OBJECTIVE: To identify the presence of surgical site infection and risk factors in patients undergoing Gynecological-Obstetric surgeries on a scheduled or emergency basis in a 2nd level of care hospital in Honduras. METHODOLOGY: Observational, descriptive, retrospective study, compiling 226 data sheets of the surgical site infection record recovered from the clinical records provided by the statistics service of the "Hospital Mario Catarino Rivas". Recruiting patients undergoing Gynecological-Obstetric surgeries, during 2017 and 2018. RESULTS: 99 tabs met the inclusion criteria, reporting an age of 24 [RIQ, 19.0 - 30.0], weight 82.0 kg [RIQ, 51.7 - 98.25], size 154 cm [150.0 - 158.0] and BMI of 25.8 ± 3.6 kg/m2. 9.1% have a history of immunosuppression. 5.1% present ISQ. 55.6% of surgeries were performed on the same day as the patient's admission. The time between antibiotic prophylaxis and the onset of surgery 60 minutes [RIQ, 40.0 - 160.0]. Duration of surgical procedures 45 minutes [RIQ, 35.0 - 55.0]. Isolated micro-morphisms in crops were Cocos gram positives (2/5), Enterococcus faecalis (1/5), Klebsiella pneumoniae (2/5). CONCLUSION: The presence of ISQ in HMCR Gynecological-Obstetric surgeries is 5.1%, identifying the following risk factors: extreme age, obesity, diabetes mellitus, immune status (HIV), early antibiotic prophylaxis; finally, technique and surgical time.

Edad gestacional, vía de parto y relación con el día y hora de nacimiento en dos instituciones del sector privado de salud / Gestational age, mode of delivery, and relation to the day and time of birth in two private health care facilities

Introducción. A nivel mundial, hay una tendencia ascendente en nacimientos prematuros y cesáreas. El objetivo fue describir edad gestacional (EG), vía de parto, distribución en días y horarios, y relación entre la vía de parto y el momento del nacimiento en dos instituciones privadas.Población y métodos. Estudio prospectivo, transversal, analítico.Resultados. Se incluyeron los 1500 nacidos vivos entre 9-2017 y 8-2018 (1465 embarazadas). El 99,4 % fueron embarazos controlados; el 66,8 % terminaron por cesárea. La causa fue cesárea previa en el 36,4 %, falta de progresión y descenso en el 18,9 % y elección materna en el 9,2 %. El peso promedio al nacer fue de 3232 g ± 561,1 g y la mediana de EG, 39 semanas (rango 38-40) por fecha de última menstruación. El 88,2 % fueron nacidos de término y, de los prematuros, el 76,1 % fueron pretérminos tardíos. Los nacidos de término temprano tuvieron mayor índice de cesáreas (p < 0,001). Los nacimientos por cesárea en días hábiles fueron 849/1201 (el 74,5 %) y, en los días de fin de semana y feriados, 173/299 (el 57,9 %, p < 0,001). Se encontró una relación estadísticamente significativa entre el horario de nacimiento y la realización de cesárea.Conclusiones. La mediana de EG fue 39 semanas. La cesárea fue la vía de nacimiento más frecuente. Los nacimientos se produjeron, predominantemente, de lunes a viernes entre las 8 y las 21 h. El 82,9 % de los nacimientos por cesárea ocurrieron en días de semana laborables

Introduction. There is a worldwide growing trend of preterm births and C-sections. Our objective was to describe gestational age (GA), mode of delivery, day and time distribution, and the relation between the mode of delivery and the time of birth in two private facilities.Population and methods. Prospective, cross-sectional, analytical study.Results. A total of 1500 live newborn infants were included between September 2017 and August 2018 (1465 pregnant women). Of these, 99.4 % had received antenatal care; 66.8 % of pregnancies ended via C-section. The reason was a previous C-section in 36.4 %, lack of progression and descent in 18.9 %, and maternal choice in 9.2 %. The average birth weight was 3232 g ± 561.1 g and the median GA was 39 weeks (range: 38-40) based on the date of the last menstrual period; 88.2 % were term births and, among preterm births, 76.1 % corresponded to late preterm babies. Early term births showed a higher rate of C-sections (p < 0.001). There were 849/1201 (74.5 %) C-sections on weekdays and 173/299 (57.9 %, p < 0.001) on weekends and holidays. A statistically significant relation was observed between the time of birth and the performance of a C-section.Conclusions. The median GA was 39 weeks. C-sections were the most common mode of delivery. Births occurred predominantly Mondays through Fridays between 8 a.m. and 9 p.m.; 82.9 % of C-sections took place on weekdays.

Gestational age, mode of delivery, and relation to the day and time of birth in two private health care facilities. / Edad gestacional, vía de parto y relación con el día y hora de nacimiento en dos instituciones del sector privado de salud.

INTRODUCTION: There is a worldwide growing trend of preterm births and C-sections. Our objective was to describe gestational age (GA), mode of delivery, day and time distribution, and the relation between the mode of delivery and the time of birth in two private facilities. POPULATION AND METHODS: Prospective, crosssectional, analytical study. RESULTS: A total of 1500 live newborn infants were included between September 2017 and August 2018 (1465 pregnant women). Of these, 99.4 % had received antenatal care; 66.8 % of pregnancies ended via C-section. The reason was a previous C-section in 36.4 %, lack of progression and descent in 18.9 %, and maternal choice in 9.2 %. The average birth weight was 3232 g ± 561.1 g and the median GA was 39 weeks (range: 38-40) based on the date of the last menstrual period; 88.2 % were term births and, among preterm births, 76.1 % corresponded to late preterm babies. Early term births showed a higher rate of C-sections (p < 0.001). There were 849/1201 (74.5 %) C-sections on weekdays and 173/299 (57.9 %, p < 0.001) on weekends and holidays. A statistically significant relation was observed between the time of birth and the performance of a C-section. CONCLUSIONS: The median GA was 39 weeks. C-sections were the most common mode of delivery. Births occurred predominantly Mondays through Fridays between 8 a.m. and 9 p.m.; 82.9 % of C-sections took place on weekdays.

Introducción. A nivel mundial, hay una tendencia ascendente en nacimientos prematuros y cesáreas. El objetivo fue describir edad gestacional (EG), vía de parto, distribución en días y horarios, y relación entre la vía de parto y el momento del nacimiento en dos instituciones privadas. Población y métodos. Estudio prospectivo, transversal, analítico. Resultados. Se incluyeron los 1500 nacidos vivos entre 9-2017 y 8-2018 (1465 embarazadas). El 99,4 % fueron embarazos controlados; el 66,8 % terminaron por cesárea. La causa fue cesárea previa en el 36,4 %, falta de progresión y descenso en el 18,9 % y elección materna en el 9,2 %. El peso promedio al nacer fue de 3232 g ± 561,1 g y la mediana de EG, 39 semanas (rango 38-40) por fecha de última menstruación. El 88,2 % fueron nacidos de término y, de los prematuros, el 76,1 % fueron pretérminos tardíos. Los nacidos de término temprano tuvieron mayor índice de cesáreas (p < 0,001). Los nacimientos por cesárea en días hábiles fueron 849/1201 (el 74,5 %) y, en los días de fin de semana y feriados, 173/299 (el 57,9 %, p < 0,001). Se encontró una relación estadísticamente significativa entre el horario de nacimiento y la realización de cesárea. Conclusiones. La mediana de EG fue 39 semanas. La cesárea fue la vía de nacimiento más frecuente. Los nacimientos se produjeron, predominantemente, de lunes a viernes entre las 8 y las 21 h. El 82,9 % de los nacimientos por cesárea ocurrieron en días de semana laborables.

Phenotypes and markers of cesarean delivery among Colombian women.

OBJECTIVE: To investigate the association of socioeconomic status (SES) components (education, occupation, and household wealth) with number (1 or ≥2) and timing (planned/emergency) of cesarean delivery (CD) in Colombia, rates of which are well above the levels recommended by the World Health Organization. METHODS: A cross-sectional study using the 2015 Demographic and Health Survey (DHS) of Colombia was carried out; 38 718 women answered the woman only module. Binomial and multinomial logistic regression analyses were conducted to generate estimates of the association between markers of SES and likelihood of CD, timing of CD, and number of CDs. RESULTS: The analysis included 9977 women. Although education and wealth were strongly associated with CD (P<0.001), the association between occupation and CD suggested that women in agriculture were the least likely to experience CD (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.44-1.03, P=0.061); and women in the "poorer" household wealth category were more likely to have emergency (OR 1.57, CI 1.29-1.90, P<0.001) and two or more (OR 1.64, CI 1.29-2.40, P<0.001) CDs. CONCLUSION: Markers of SES are associated with CD overuse in Colombia, as well as the number and timing of CD. More robust qualitative inquiry including additional questions to the DHS survey are needed to elucidate reasons driving the overutilization of CD in the country, particularly among vulnerable populations.

Publicly insured caesarean sections in private hospitals: a repeated cross-sectional analysis in Chile.

OBJECTIVE: To measure the likelihood of delivery by caesarean section (C-section) for publicly insured births as compared with privately insured births, across all hospitals and within private hospitals. DESIGN: Repeated cross-sectional analysis. SETTING: The universe of hospital births in 15 regions of Chile. PARTICIPANTS: 2 405 082 singleton births between 2001 and 2014. OUTCOME MEASURES: C-section rates by type of hospital and type of insurance; contribution to overall C-section rates of subgroups by type of insurance and type of hospital; adjusted OR of privately insured births delivered by C-section compared with publicly insured births, across all hospitals and within private hospitals; percentage of discharges related to maternal morbidity and mortality across groups; length of stay after delivery. RESULTS: An increasing percentage of publicly insured births occur in private facilities each year. Approximately three out of four publicly insured births in private hospitals are delivered by C-section. The adjusted odd of C-section delivery in a private maternity unit is lower for those privately insured than for those with public insurance: OR 0.6, 95% CI 0.56 to 0.64. There is no evidence that these women would have been more likely to have a C-section out of medical necessity. CONCLUSIONS: We find an association between high C-section rates and publicly insured women delivering at private institutions in Chile, and show that this group is driving the overall high and growing rates. There is a need for a more informed surveillance on the part of the public insurance system of its private providers' C-section practices.

¿Qué sabemos de la importancia de la microbiota intestinal a lo largo de la vida? / What do we know about intestinal microbiota through the life cycle?

Over the last decades, modern lifestyle and environment have contributed to a shift in gut microbial colonization patterns and composition. Not only intestinal but also extraintestinal disorders have been proposed to be linked to changes in the gut microbiome. There is increasing evidence from clinical, epidemiologic and animal studies exploring associations between the dysbiotic microbiome and an increased risk of allergic, inflammatory, autoimmune, and metabolic diseases. The fetus is essentially sterile until the amniotic sac ruptures. After that, the maternal microbiota of the mouth, intestine, vagina and urinary tract contribute to the initial seeding of neonatal microbiota. Newborns are mainly inoculated at birth in the passage through the birth canal (vertical transmission). A number of exposure events occur afterwards (horizontal transmission), and by age 2, an infant's microbiota composition becomes indistinguishable from that of an adult. In mammalian evolution, the potential loss or change in vertical transmission of microbiota from mother to offspring could be compensated through horizontally transmitted microbiota (fecally contaminated drinking and bathing water, frequent physical contact, social crowding, and large families). However, the progressive loss of vertically transmitted microbiota without horizontal replacement represents a cumulative birth cohort phenomenon. Events that decrease microbiota diversity have been classically associated with risk of disease

En las últimas décadas, el estilo de vida y el ambiente moderno, han contribuido a un cambio en los patrones y la composición de colonización microbiana intestinal. No sólo se ha propuesto que los trastornos intestinales, sino también los extraintestinales, estarían relacionados con cambios en la microbioma intestinal. Cada vez hay más evidencias de estudios clínicos, epidemiológicos y en animales que exploran las asociaciones entre el microbioma disbiótico y un mayor riesgo de enfermedades alérgicas, inflamatorias, autoinmunes y metabólicas. El feto es esencialmente estéril hasta que el saco amniótico se rompe. Después de eso, la microbiota materna de la boca, el intestino, la vagina y el tracto urinario contribuye a la siembra inicial de la microbiota neonatal. Los recién nacidos se inoculan principalmente al nacer en el pasaje a través del canal de parto (transmisión vertical). Después de una serie de eventos de exposición (transmisión horizontal), a los 2 años, la composición de microbiota de un bebé se vuelve indistinguible de la de un adulto. En la evolución de los mamíferos, la pérdida o cambio potencial en la transmisión vertical de la microbiota de la madre a la descendencia podría compensarse mediante la microbiota transmitida horizontalmente (agua potable y de baño contaminada con heces, contacto físico frecuente, aglomeración social y familias numerosas). Sin embargo, la pérdida progresiva de microbiota transmitida verticalmente sin reemplazo horizontal representa un fenómeno de cohorte de nacimiento acumulativo. Los eventos que disminuyen la diversidad de la microbiota se han asociado clásicamente con el riesgo de enfermedad.

Cesárea perimortem por trauma penetrante por proyectil de arma de fuego con supervivencia fetal. Reporte de un caso / Perimortem C-Section after gunshot penetrating trauma with infant survival. Case report

Resumen Introducción: El trauma en el embarazo es un escenario complejo, y pocas publicaciones estudian los problemas secundarios a éste en el tercer trimestre, como es el caso de las indicaciones y resultados de las cesáreas de emergencia. La cesárea perimortem es un acontecimiento inusual; cuando se realiza, es el único recurso para obtener un recién nacido vivo. Si existe paro cardiorrespiratorio, la cesárea perimortem está indicada después de 4 a 5 minutos de inicio del paro en la madre. Caso: Mujer de 19 años, con antecedente de herida por proyectil de arma de fuego, que ingresó al cubículo de choque en paro y con maniobras de reanimación cardiopulmonar y embarazo de aproximadamente 36 semanas de gestación. Se realizaron 4 ciclos de reanimación sin reversión a circulación espontánea; por lo cual se decidió realizar cesárea de emergencia perimortem por un cirujano general en el área de choque. Se obtuvo un producto único vivo, y se reportó la defunción de la madre minutos después. Se trasladó el producto a la Unidad de Cuidados Intensivos Neonatales (UCIN), y 5 días después del procedimiento se reportó sin secuelas neurológicas. Conclusión: La primera razón para realizar de una cesárea perimortem es la supervivencia de la madre. Como se trata de una emergencia, no es necesario invertir tiempo en verificar la viabilidad fetal. En casos especiales, en los que debido a su patología la posibilidad de supervivenciade la madre es nula, la cesárea perimortem podrá realizarse para salvar la vida del producto. Realizar este procedimiento requiere tomar una decisión muy importante y de manera muy rápida, hay que resaltar la importancia del lugar donde se realizó, ya que era un centro de trauma, donde se cuenta con salas de choque especializadas para realizar procedimientos de emergencia con mayor rapidez, y personal capacitado sin necesidad de trasladarse a un quirófano para realizarlo, para obtener resultados satisfactorios.

Abstract Introduction: Trauma in pregnancy is a complex scenario, few publications study the issues after trauma in the 3rd trimester, including indications and outcomes in emergency C-Section. Perimorten Cesarean Section, is an unusual event, when it's performed it is the only resource for infant survival. When there is cardiac arrest, Perimortem Cesarean Section is indicated 4 to 5 minutes after cardiac arrest. Case: 19 year old female, with recent history of gunshot injury to the chest, arrives in cardiac arrest and with CPR and a 36 week pregnancy. 4 cycles of Cardiopulmonary resuscitation where performed without reversion to spontaneous circulation, then we decide to perform a Perimortem Cesarean Section by General Surgeon in the trauma room. Infant alive t is obtained, death of the mother is reported minutes later. The infant is transferred to NICU, 5 days after the procedure, it is reported without neurological sequelae. Conclusion: The first reason to perform a perimortem cesarean section is the survival of the mother, because it's an emergency, it's not necessary to lose time in verifying the infant's vitals. In special cases, in which there are few possibilities of mother survival, the perimortem cesarean section is performed for infant survival. Performing this procedure requires a very important decision making and in a quick way, it's very important to remark that this procedure was performed in a Trauma Center, which has the facilities as a trauma room, where we can do emergency procedures faster, and with the trained medical staff to do it, with no need to move to an operating room to perform it, obtaining successful outcomes.

Factors associated with the use of supplemental oxygen or positive pressure ventilation in the delivery room, in infants born with a gestational age ≥ 34 weeks.

BACKGROUND: Approximately 5-10 % of newborns require some form of resuscitationupon delivery; several factors, such as maternal abnormal conditions, gestational age and type of delivery could be responsible for this trend. This study aimed to describe the factors associated with the need for positive pressure ventilation (PPV) via a mask or endotracheal tube and the use of supplemental O2 in newborns with a gestational age greater than 34 weeks in Brazil. METHODS: We performed a cross-sectional study and obtained data from the Birth in Brazil Survey. The inclusion criterion was a gestational age ≥34 weeks. Exclusion criteria were newborns with congenital malformations, and cases with undetermined gestational age or type of delivery (vaginal, pre labor cesarean section and cesarean section during labor). The primary outcomes were need of PPV via a mask or endotracheal tube and the use of supplemental oxygen without PPV. Confounding variables, including maternal age, source of birth payment, years of maternal schooling, previous birth, newborn presentation, multiple pregnancy, and maternal obstetric risk, were analyzed. RESULTS: We included 22,720 newborns. Of these, 2974 (13.1 %) required supplementary oxygen. PPV with a bag and mask was used for 727 (3.2 %) newborns and tracheal intubation for 192 (0.8 %) newborns. Chest compression was necessary for 136 (0.6 %) newborns and drugs administered in 114 (0.5 %). 51.3 % of newborns were delivered by cesarean section, with the majority of cesarean sections (88.7 %) being performed prior to labor. Gestational age (late preterm infants: (Relative Risk-(RR) 2.46; 95 % (Confidence interval-CI 1.79-3.39), maternal obstetric risk (RR 1.59; 95 % CI1.30-1.94), and maternal age of 12-19 years old (RR 1.36; 95 % CI1.06-1.74) contributed to rates of PPV in the logistic regression analysis. Newborns aged between 37-38 weeks of gestaional age weren´t less likely to require PPV compared with those aged 39-41 weeks of gestational age. CONCLUSIONS: Late preterm infants, previous maternal obstetric risks and maternal age contributed to the higher needs of PPV and use of O2 in the delivery room. These variables need to be considered in planning care in the delivery room.

New challenges beyond nutrition: c-section, air pollution and domestic violence.

The DOHaD research field has successfully associated adult non-communicable diseases with inadequate nutrition in early periods of life. More recently, different types of exposure have been linked with impaired developmental outcomes and later health consequences, such as cesarean section at delivery, air pollution and domestic violence during pregnancy. The aim of this work is to bring up this issue looking at the published evidence on these three highly prevalent hazards in Latin American countries.

Fatores associados à via de parto atual em mulheres com cesariana prévia / Factors associated with mode of delivery in present pregnancy in women with previous caesarean section

O aumento alarmante e crescente das taxas de cesariana é realidade mundial, representando problema de saúde pública, por se associar a maior morbidade materna e fetal além de elevados custos hospitalares. Uma das principais estratégias para diminuir esses índices é submeter a paciente com uma cesariana anterior à prova de trabalho de parto. O objetivo deste estudo foi descrever o desfecho neonatal e via de parto de pacientes com história de cesariana em gestação anterior e compará-los a primíparas. Foram avaliadas 188 mulheres, 94 em cada grupo, no período de janeiro a abril de 2010. A taxa global de cesariana foi de 42%. Nas primíparas 38,2%, e nas pacientes com uma cesariana anterior 77,6%. Apenas 46,8% das pacientes com uma cesariana anterior foram submetidas à prova de trabalho de parto, neste grupo a frequência de parto normal foi de 44,19%. Não houve diferença no desfecho neonatal ou obstétrico entre os grupos. Conclusão: Uma cesariana anterior aumenta em 5,6 vezes a chance de uma nova cesariana na gestação atual se comparadas à primíparas.

The alarming increase and rising rates of caesarean section is a worldwide reality, representing a public health problem, associated with increased maternal and fetal morbidity and higher hospital costs. A strategy to reduce these rates is to submit a patient with a previous cesarean to a trial of labour (VBAC). The objective of this study was to describe neonatal outcome and mode of delivery in patients with a cesarean section in previous pregnancy compared with primiparous. We evaluated 188 women, 94 in each group during the period from January to April 2010. The epidemiological profile of patients who had vaginal delivery or cesarean section were similar. The overall rate of cesarean section was 42%. In primiparous 38.2% and 77,6 % in patients with a previous cesarean section. Only 46.8% of patients with a previous cesarean section were submitted a trial of labor after c-section, in this group the frequency of vaginal delivery was 44.19%. There was no difference in neonatal outcome between groups. Conclusion: a previous caesarean section increases by 5.6 times the chance of a new caesarean section in the current pregnancy compared to primiparous women.

Spatial distribution of C-sections within the state of São Paulo / Distribuição espacial das cesarianas no Estado de São Paulo

Objective: to identify spacial patterns for cesarean deliveries per microregion in the state of São Paulo. Methods: this is an ecological and exploratory study with data on live births occurred between 2003 and 2007 in 63 microregions in the state of São Paulo. Variables analyzed included cesarean delivery rates, teenage mothers, mothers with high levels of education and who had at least seven prenatal consultations. Moran's index (I), a measure of spatial autocorrelation of rates related to the variables described above and which identifies the presence of spatial clusters, was calculated. The distributions of the variables' rates in this study were visualized using thematic maps. The Moran map was used to identify microregions with high priority need for attention. Pearson correlation coefficients among the variables were also obtained. Results: there were 3,045,293 births, being 1,636,009 (53.7 %) cesarean deliveries. It was possible to identify spatial clusters of C-sections (I = 0.58 and p < 0.01) in the microregions located on the north and northwest of the state of São Paulo, as well as in Guaratinguetá; the values found for Moran index were, I = 0.32, I = 0.30 and I = 0.24, for the rates of teenage mothers, schooling and number of consultations, respectively, being all significant results (p <0.01). Micro-regions with high-priority need for attention were identified. Cesarean rates were significantly correlated with high rates of maternal education and number of prenatal consultations. Conclusion: the identification of these microregion clusters with high rates of cesarean delivery allows health managers to implement policies in order to minimize these rates. .

Objetivo: identificar padrões espaciais para partos cesarianos por microrregião do Estado de São Paulo. Métodos: estudo ecológico e exploratório com dados de nascidos vivos entre 2003 e 2007 de 63 microrregiões do Estado de São Paulo. As variáveis analisadas neste estudo foram, além de taxas de parto cesariano, taxas de mães adolescentes, de mães com alta escolaridade e de mães que realizaram pelo menos 7 consultas no pré-natal. Foram calculados os índices de Moran (I), que estimam autocorrelação espacial das taxas das variáveis acima descritas e identificam a presença de aglomerados espaciais. Essas taxas foram visualizadas pelos mapas temáticos; microrregiões com alta prioridade de atenção foram identificadas pelo mapa de Moran. Foram calculados os coeficientes de correlação de Pearson entre as variáveis. Resultados: houve 3.045.293 partos, sendo 1.636.009 (53,72%) partos cesarianos. Foi possível identificar aglomerados espaciais de cesarianas (I = 0,58 e p < 0,01) nas microrregiões ao norte e noroeste do Estado, além de Guaratinguetá. Os valores dos índices de Moran foram, para as taxas de mães adolescentes, I = 0,32; para as taxas de alta escolaridade, I = 0,30; e para as taxas do número de consultas, I = 0,24, todos significativos (p<0,01). Foram identificadas microrregiões com alta prioridade de intervenção. As taxas de cesarianas estiveram correlacionadas significativamente com as taxas de alta escolaridade materna e com número de consultas. Conclusão: a identificação desses aglomerados de microrregiões com altas taxas de cesarianas permite aos gestores de saúde implantar políticas para minimizar tais taxas. .

Características sociodemográficas y reproductivas asociadas con el aumento de cesáreas en México / Sociodemographic and reproductive characteristics associated with the increase of cesarean section practice in Mexico

Objetivo. Describir la tendencia de la cesárea en México y su asociación con características sociodemográficas y reproductivas. Material y métodos. Con base en En-cuestas Nacionales de Salud 2000, 2006 y 2012, se analizó información de cesáreas en mujeres. Se utilizó un modelo de regresión logística multivariado en 2012. Resultados. Se identificó un incremento de 50.3% de la operación cesárea a nivel nacional en el periodo de 2000 a 2012. Las mujeres con mayor posibilidad de tener una cesárea fueron las que se atendieron en el sector privado (RM=2.84, 95%IC:2.153.74). Al asociar la edad y la paridad se observan los riesgos más altos en primíparas de 12 a 19 y de 35 o más años (RM=6.02, 95%IC:1.24-29.26 y RM=5.20, 95%IC:2.41-11.21, respectivamente). Conclusiones. Se proponen algunas recomendaciones encaminadas a revertir el incremento de esta práctica clínica, sobre todo en aquellos casos donde no hay una indicación precisa para su realización.

Objective. To describe the trend of cesarean section practice in Mexico, and its association with women's sociodemographic and reproductive characteristics. Materials and methods. Based on the 2000, 2006 and 2012 National Health Surveys, information on c-section was analyzed. A multivariate logistic regression model was used in 2012. Results. A 50.3% increase in the use of c-section was observed nationally from 2000 to 2012. Women more likely to undergo a c-section include those whose delivery care takes place in the private sector (OR=2.84, 95%CI:2.15-3.74). When associating women's age and parity, the greatest risks are observed among primiparous women between 12 and 19 years of age, and those aged 35 years and more (OR=6.02, 95%CI:1.24-29.26 and OR=5.20, 95%CI:2.41-11.21, respectively). Conclusions. Some recommendations to revert the increase of this clinical practice, especially when there is no full justification for its realization, are proposed.

Hipotensión en anestesia regional y velocidad de inyección / Hypotension in regional anesthesia and rate of injection

Introducción. Realizar una reflexión sobre el artículo “Anestesia regional subaracnoidea para cesárea y Pomeroy postparto. Aplicación de anestésico local a una velocidad de inyección menor o mayor a 60 segundos”, para aproximar al lector a otra perspectiva de los resultados presentados. Métodos. Se realizó una lectura crítica del artículo mencionado, con el fin de evaluar la calidad metodológica del mismo, las posibles fuentes de sesgo y de error, las variables de confusión y también para revisar los resultados desde esta nueva mirada. Resultados. La hipotensión es un desenlace frecuente cuando se aplica anestesia subaracnoidea y la velocidad de inyección de la misma puede ser parte de su causa. La serie de casos analizada tiene un tamaño de muestra limitado, por lo que en el estudio se puede presentar sesgo de información y factores de confusión, además de no haberse tenido en cuenta una posible interacción entre la velocidad de infusión y las mezclas de anestésicos empleados. Conclusión. Es necesario realizar un estudio de cohorte con mayor tamaño de muestra, el cual permita controlar la confusión mediante la estandarización de los procedimientos, el análisis estratificado por subgrupos y el modelamiento matemático para identificar tanto la fuerza de asociación entre la velocidad de inyección del anestésico y la aparición de hipotensión, como las posibles fuentes de confusión e interacción allí presentes.

Introduction. To present some thoughts on the article “Regional subarachnoid anesthesia for C-section and post-partum Pomeroy procedure. Application of a local anesthetic at a rate lower or greater than 60 seconds” in order to provide readers with a different perspective regarding the results reported. Methods. The paper was read critically in order to assess the quality of the methodology, the potential sources of bias and error, the confounding variables, and also to review the results from a fresh perspective. Results. Hypotension occurs frequently when subarachnoid anesthesia is applied, and the rate of injection may explain it in part. The case series analyzed has a limited sample size, creating the possibility of information bias and confounding factors, not to mention that the potential interaction between the rate of infusion and the mix of anesthetics was not considered. Conclusion. A cohort study with a larger sample size must be undertaken in order to control confusion by means of standardized procedures, an analysis stratified by subgroups, and mathematical modeling designed to identify the strength of association between the injection rate and the onset of hypotension, as potential sources of confusion and interaction.

El punto ciego de la anestesia obstétrica: monitoría fetal intraquirúrgica / The blind spot in obstetric anesthesia: intra-surgical fetal monitoring

Introducción. La monitoría fetal en pacientes obstétricas que son intervenidas de operación cesárea tiene un gran vacío, que corresponde al periodo transoperatorio. Pese al desarrollo vertiginoso de la tecnología en todos los ámbitos de la medicina, no ha sido posible establecer un método práctico para evaluar el bienestar fetal durante la cesárea. Objetivo. Se propone encontrar y diseñar un métodono invasivo y práctico que se pueda aplicar en un sitio distante al campo quirúrgico abdominal y que registre la frecuencia fetal continua como medida indirecta del bienestar fetal. Esta labor no solo atañe al anestesiólogo, sino, también, al obstetra y al pediatra. Metodología. Artículo de reflexión que surge luego de una pregunta realizada por estudiantes de anestesiología en el quirófano (pregrado y posgrado),sobre un método práctico de monitoría fetal no invasiva intraoperatoria. Se realizó busqueda en bases de datos de Medline, Ovid y Science Direct. Resultados. Actualmente, no hay un método de monitoría fetal apropiado (óptimo y práctico) para este periodo en el quirófano; es imperioso encontrar una salida por medio de la tecnología, que permita evaluar el bienestar fetal en el transoperatorio de la cesárea, en primera instancia, porque el tiempo quirúrgico tiene muchos factoresque lo pueden prolongar y ser un determinante en la falta de control de un evento hipóxico o isquémico en el feto; también, porque la seguridaden anestesia obstétrica y fetal debe ser exigente y crítica.

Introduction: There is a big gap in fetal monitoring in obstetric patients undergoing cesarean section during the transoperative period. Despite the astonishing technological developmentsin all medical areas, we have failed todevelop a practical method for the evaluation of the fetus wellbeing during a c-section intervention. Objective. A non-invasive and practical methodis suggested that can be used in a site distant from the abdominal surgical field to record the continuous fetal heart rate as an indicator of fetal wellbeing. This task would not only involve the anesthesiologist, but the obstetrician andthe pediatrician as well. Methodology. Producing an article that should be food for thought, based on a question askedby students of anesthesiology in the OR (graduate and postgraduate students), about a practical method for intraoperative fetal, noninvasivemonitoring. The search was conductedusing the Medline, Ovid and Science Direct data basis. Results. Notwithstanding the absence of an appropriate fetal monitoring method (optimal and practical) for this period of time in the OR, it is mandatory to find a technology-based solution to assess the wellbeing of the fetus during thetransoperative period of the c-section, firstly because there are multiple factors that may extend the surgical time and become a determining factorfor the lack of control of a hypoxic or schemic event of the fetus; secondly, because safety of obstetric and fetal anesthesia must be demandingand is critical.