[The Role of Oxytocin in the Prevention of Postpartum Hemorrhage in Low-Resource Settings]. / O Papel da Ocitocina na Profilaxia da Hemorragia Pós-Parto em Locais com Recursos Limitados.

INTRODUCTION: Postpartum hemorrhage remains one of the leading causes of maternal death globally. Oxytocin is the uterotonic agent of choice for the prophylaxis of this complication. However, its use in low-resource settings is associated with clinical, political, economic and cultural constraints. The goal of this article is to describe the use of oxytocin for postpartum hemorrhage prophylaxis in low-resource settings. MATERIAL AND METHODS: A literature review on the topic was carried out, and 24 articles were included. RESULTS: The information was organized into seven sections: the evaluation of the efficacy of oxytocin compared to other uterotonics, the use of oxytocin in home births, the training of healthcare professionals, the quality of the available oxytocin, the new formulations, the risks associated with the use of uterotonic and the adopted health policies. DISCUSSION: Despite the progress achieved widespread access to oxytocin for postpartum hemorrhage prophylaxis in low-resource settings is less than desirable. The main difficulties encountered were the shortage of skilled healthcare professionals for oxytocin administration, deficiencies concerning the quality of the drug and the inadequacy of available clinical guidelines. CONCLUSION: In order to reduce maternal mortality caused by postpartum hemorrhage in low-resource settings, it is essential to improve the knowledge of healthcare professionals, to implement good practices on the use of uterotonics, to optimize resource management and to overcome cultural barriers that prevent the demand for health services.

Introdução: A hemorragia pós-parto mantém-se como uma das principais causas de morte materna a nível global. A ocitocina é o uterotónico de eleição na profilaxia desta complicação. Contudo, a sua utilização em locais com recursos limitados associa-se a constrangimentos de foro clínico, político, económico e cultural. O objetivo deste artigo é rever o uso da ocitocina na profilaxia da hemorragia pós-parto em locais com recursos limitados.Material e Métodos: Foi efetuada uma revisão da literatura sobre o tema, selecionando-se 24 artigos.Resultados: A informação foi organizada em sete secções: a avaliação da eficácia da ocitocina relativamente a outros uterotónicos, a utilização da ocitocina em partos domiciliários, a capacitação dos profissionais de saúde, a qualidade da ocitocina disponibilizada nestes locais, as novas formulações, os riscos inerentes à utilização de uterotónicos e as políticas de saúde adotadas.Discussão: Apesar dos progressos alcançados, verificámos que o acesso à profilaxia da hemorragia pós-parto com ocitocina em locais com recursos limitados está aquém do desejável. As principais dificuldades encontradas foram o défice de profissionais de saúde qualificados na administração da ocitocina, as deficiências na qualidade do fármaco e a desadequação das normas de orientação clínica existentes.Conclusão: Para reduzir a mortalidade materna por hemorragia pós-parto em locais de recursos limitados é imprescindível melhorar a capacitação dos profissionais, implementar boas práticas no uso de uterotónicos, otimizar a gestão de recursos e transpor as barreiras culturais impeditivas da procura dos serviços de saúde.

Building a Maternal and Newborn Care Training Programme for Health-Care Professionals in Guinea-Bissau.

INTRODUCTION: The Integrated Programme of Maternal and Child Health aims to reduce maternal and child mortality in Guinea-Bissau. The purpose of this article is to share our experience in building a training programme on maternal and newborn care for health-care professionals in Guinea-Bissau. MATERIAL AND METHODS: Regional directors of the four target areas chose a group of staff who provide prenatal and childbirth care to attend the course (12 to 15 trainees per region). In each region, 15 highly interactive and practical sessions were scheduled over eight weeks. The trainees' summative and reactive assessment was obtained using a multiple choice questionnaire (final test) and an anonymous survey, respectively. RESULTS: Attendees included 25 nurses, 17 midwives and 14 doctors. About two thirds had five years' practice or less. Test median scores were higher among trainees with two to nine years of practice (54.4% to 60.9%), as compared to those with a year or less (47.8%) or 10 or more years (45.7%). Pedagogical variables were rated as 'good' or 'very good' by 91% to 95% of the attendees. DISCUSSION: Use of an interactive and practical pedagogical methodology produced positive results and was crucial to tailoring the training to local needs. However, adapting the syllabus according to professional categories and experiences should be considered. CONCLUSION: Our results warrant further development and evaluation of training programmes on maternal and neonatal care in Guinea-Bissau.

Introdução: O Programa Integrado de Saúde Materna e Infantil visa reduzir a mortalidade materno-infantil na Guiné-Bissau. O objetivo deste artigo é partilhar a experiência no desenvolvimento do treino em cuidados maternos e ao recém-nascido, em quatro regiões da Guiné-Bissau. Material e Métodos: Os diretores regionais indicaram 12 a 15 profissionais que prestavam assistência pré-natal e ao parto para participarem no treino. Durante oito semanas, 15 sessões predominantemente interativas e práticas foram ministradas em cada região. Foram efetuadas avaliações sumativa e reativa através de um teste final com perguntas de escolha múltipla e de um questionário de satisfação anónimo, respetivamente. Resultados: Participaram no treino 25 enfermeiras, 17 parteiras e 14 médicos. Praticamente dois terços tinham cinco ou menos anos de prática clínica. Os resultados do teste final foram superiores nos formandos com dois a nove anos de experiência (medianas de 54,4% a 60,9%), comparativamente àqueles até um ano (47,8%) ou com 10 ou mais anos (45,7%). As variáveis pedagógicas foram classificadas como 'bom' ou 'muito bom' por 91% a 95% dos participantes. Discussão: A metodologia interativa e prática produziu bons resultados e foi muito útil para moldar o treino às necessidades locais. Contudo, o programa de estudos deve ser adaptado de acordo com categorias e experiências profissionais. Conclusão: Os resultados obtidos justificam o desenvolvimento e a avaliação adicional de programas de formação em cuidados de saúde materna e neonatal na Guiné-Bissau.

Uterine artery Doppler in the management of early pregnancy loss: a prospective, longitudinal study.

BACKGROUND: The pharmacological management of early pregnancy loss reduced substantially the need for dilation and curettage. However, prognostic markers of successful outcome were not established. Thus the major purpose of this study was to determine the sensitivity and specificity of the uterine artery pulsatility (PI) and resistance (RI) indices to detect early pregnancy loss patients requiring dilation and curettage after unsuccessful management. METHODS: A cohort prospective observational study was undertaken to include women with early pregnancy loss, ≤ 12 weeks of gestation, managed with mifepristone (200 mg) and misoprostol (1600 µg) followed by PI and RI evaluation of both uterine arteries 2 weeks after. At this time, in 173/315 patients, incomplete miscarriage was diagnosed. Among them, 32 underwent uterine dilatation and curettage at 8 weeks of follow-up. RESULTS: The cut-off points for the uterine artery PI and RI, leading to the maximum values of sensitivity (69.5%, CI95%: 61.5%-76.5% and 75.0%, CI95%: 57.9%-86.8%, respectively) and specificity (75.0%, CI95%: 57.9%-86.8% and 65.6%, CI95%: 48.3%-79.6%, respectively), for the discrimination between the women who needed curettage from those who resolved spontaneously were 2.8 and 1, respectively. CONCLUSIONS: The potential usefulness of uterine artery Doppler evaluation to predict the need for uterine curettage in patients submitted to medical treatment for early pregnancy loss was demonstrated.

[Use of simulation-based methodologies for teaching and learning in Portuguese medical schools]. / Utilização das metodologias de simulação médica no ensino e aprendizagem nas escolas médicas Portuguesas.

The main purpose of medical simulation is for students and healthcare professionals to learn, individually or as team members. A questionnaire was developed on the use of medical simulators or simulation-based techniques applied to Medicine, and sent to the directors of all medical schools in Portugal (n = 7). The aim was to contribute to a better understanding of teaching through the use of simulation applied to Medicine. In the curricular year of 2006-07 all medical schools used simulators, or techniques of medical simulation, in their pre-graduate training in Medicine. A small number of other initiatives in pre-and post-graduate medical training were also reported. Despite these activities, there is still a large potential for expansion of simulation-based teaching methodologies in Portuguese medical schools. The growing number of students admitted to medical courses, together with the increase in medico-legal conflicts, leads to a need for curricular developments and adjustments in teaching methodologies.

Self-perceived impact of simulation-based training on the management of real-life obstetrical emergencies.

OBJECTIVE: To evaluate the self-perceived impact of attending a simulation-based training course on the management of real-life obstetrical emergencies. STUDY DESIGN: A prospective follow-up study was conducted. Obstetric nurses and obstetricians (n=54) from a tertiary care university hospital participated in a simulation-based training course for the management of four obstetric emergencies. One year after the last session of the course, participants were asked to complete a questionnaire evaluating the self-perceived impact it had on their knowledge, technical skills, and teamwork skills during experienced real-life situations. A five-point Likert grading scale was used. The χ(2) test with one degree of freedom or the Fisher's exact test were used to compare groups of participants. The t-test for independent samples was used to compare mean scores between groups. RESULTS: A total of 46 healthcare professionals answered the questionnaire: 27 obstetricians and 19 obstetric nurses. Of these, 87% perceived an improvement (scores 4 or 5) in their knowledge and skills during real emergencies. Obstetric nurses expressed a significantly higher improvement than obstetricians in their ability to diagnose or be aware of obstetrical emergencies (p=0.002), in their technical skills (p=0.024), and in their ability to deal with teamwork related issues (p=0.005). Participants who had experienced in real-life situations all four simulated scenarios rated the impact of training significantly higher than others (p=0.049), and also reported a better improvement in their knowledge of management guidelines (p=0.006). CONCLUSIONS: Healthcare professionals who participated in a simulation-based training course in obstetrical emergencies perceived a substantial improvement in their knowledge and skills when witnessing real-life emergencies. Improvements seem to be particularly relevant for obstetric nurses and for those who witness all trained obstetrical emergencies.

[Shoulder dystocia: an obstetrical emergency]. / Distócia de ombros: uma emergência obstétrica.

Shoulder dystocia is one of the most feared obstetric emergencies due to related maternal and neonatal complications and therefore, the growing of medico-legal litigation that it entails. Although associated with risk factors such as fetal macrossomia, gestacional diabetes and instrumented delivery, the majority of cases are unpredictable. The lack of a consensus on shoulder dystocia diagnosis causes variations on its incidence and hampers a more comprehensive analysis. Management guidelines described for its resolution include several manoeuvres but the ideal sequence of procedures is not clearly defined in more severe cases. Hands-on and team training, through simulation-based techniques applied to medicine, seems to be a promising method to learn how to deal with shoulder dystocia having in mind a reduction in related maternal or neonatal morbidity and mortality. The main goal of this paper is to provide a comprehensive revision of shoulder dystocia highlighting its relevance as an obstetric emergency. A reflection on the management is presented emphasising the importance of simulation-based training.

The modified Misgav-Ladach versus the Pfannenstiel-Kerr technique for cesarean section: a randomized trial.

BACKGROUND: Modifications to the classic cesarean section technique described by Pfannenstiel and Kerr have been proposed in the last few years. The objective of this trial was to compare intraoperative and short-term postoperative outcomes between the Pfannenstiel-Kerr and the modified Misgav-Ladach (MML) techniques for cesarean section. METHODS: This prospective randomized trial involved 162 patients undergoing transverse lower uterine segment cesarean section. Patients were allocated to one of the two arms: 88 to the MML technique and 74 to the Pfannenstiel-Kerr technique. Main outcome measures were defined as the duration of surgery, analgesic requirements, and bowel restitution by the second postoperative day. Additional outcomes evaluated were febrile morbidity, postoperative antibiotic use, postpartum endometritis, and wound complications. Student's t, Mann-Whitney, and Chi-square tests were used for statistical analysis of the results, and a p < 0.05 was considered as the probability level reflecting significant differences. RESULTS: No differences between groups were noted in the incidence of analgesic requirements, bowel restitution by the second postoperative day, febrile morbidity, antibiotic requirements, endometritis, or wound complications. The MML technique took on average 12 min less to complete (p = 0.001). CONCLUSION: The MML technique is faster to perform and similar in terms of febrile morbidity, time to bowel restitution, or need for postoperative medications. It is likely to be more cost-effective.

[Influence of three organisational measures on the cesarean section rate in a tertiary care University Hospital]. / Influência de três medidas organizativas na redução da taxa de cesarianas de um Hospital de Apoio Perinatal Diferenciado.

OBJECTIVE: To evaluate the influence of three organizational measures on the cesarean section rate over two consecutive years, in the Department of Obstetrics and Gynaecology of a tertiary care University Hospital. MATERIAL AND METHODS: Clinical records of births occurring in the years 2001 and 2002 were retrospectively evaluated, in order to identify the annual rate of emergency and elective cesarean sections. Other data recorded were the type of deliveries in each on-call team, newborn 1-min and 5-min Apgar scores, neonatal intensive care unit admissions, principal motive for emergency cesareans, time of day and week-day of emergency cesareans. In the first week of 2002, the results of the first year's evaluation were presented to all staff at the Department. At that time, an information pamphlet was distributed to all health care professionals, reminding them of the risks associated with cesarean section. From then on, all emergency cesareans were discussed on the following work-day, in a clinical meeting involving all obstetrical staff. Statistical analysis was carried out using the chi-squared test, with the level of significance being established at 0.05. RESULTS: In 2001 there were 3009 births, overall cesarean section rate was 36.5%, and emergency cesarean rate was 30.5%. Cesarean section rates varied between 23.3% and 43.4%, amongst the eight on-call teams. In 2002 there were 2959 births, overall cesarean section rate was 27.6%, and emergency cesarean rate was 20.4%. Cesarean section rates in on-call teams varied between 14.3% and 31.5%. Over the two years, a reduction of 8.9 percentage points (p<0.001) in overall cesarean section rate, and of 10.1 points (p<0.001) in emergency cesareans were observed. During the same period elective cesareans increased 1.2 percentage points (p=0.052) and instrumental deliveries increased 3.2 points (p=0.002). There were less cesarean sections due to arrested labour (154 cases) and non-reassuring fetal state (46 cases), although these motives remained preponderant. The number of newborns with low 1-min Apgar decreased significantly, while those with low 5-min Apgar and intensive care unit admission remained constant. CONCLUSIONS: The introduction of three relatively simple organizational measures enabled a significant reduction in the cesarean section rate over a one-year period, without changing the incidence of the main neonatal outcome indicators.