RESUMO
In pregnant patients at term undergoing induction of labor, early time-based artificial rupture of membranes (AROM) within 1 hour of Foley bulb expulsion results in a shorter duration of labor by nearly 9 hours with no significant difference in cesarean delivery rates or maternal or neonatal adverse outcomes.1.
Assuntos
Amniotomia , Maturidade Cervical , Gravidez , Feminino , Recém-Nascido , Humanos , Cesárea , Fatores de Tempo , Trabalho de Parto Induzido/métodosRESUMO
BACKGROUND: Vaginal examination to monitor labor progress is recommended at least every 4 hours, but it can cause pain and embarrassment to women. Trial data are limited on the best intensity for vaginal examination. Vaginal examination is not needed for oxytocin dose titration after an amniotomy has been performed and oxytocin infusion started. The Foley balloon commonly ripens the cervix without strong contractions. Amniotomy and oxytocin infusion are usually required to drive labor. OBJECTIVE: This study aimed to evaluate the first vaginal examination at 8 vs 4 hours after amniotomy-oxytocin after Foley ripening in multiparous labor induction. STUDY DESIGN: A randomized controlled trial was conducted from October 2021 to September 2022 at the University Malaya Medical Center, Kuala Lumpur, Malaysia. Multiparas at term were recruited at admission for labor induction. Participants were randomized to a first routine vaginal examination at 8 or 4 hours after Foley balloon ripening and amniotomy. Titrated oxytocin infusion was routinely commenced after amniotomy to initiate contractions. The 2 primary outcomes were the time from amniotomy to delivery (noninferiority hypothesis) and maternal satisfaction (superiority hypothesis). Data were analyzed using the Student t test, Mann-Whitney U test, and chi-square test (or Fisher exact test), as suitable for the data. RESULTS: A total of 204 women were randomized, 102 to each arm. Amniotomy to birth intervals were 4.97±2.47 hours in the 8-hour arm and 5.79±3.17 hours in the 4-hour arm (mean difference, -0.82; 97.5% confidence interval, -1.72 to 0.08; P=.041; Bonferroni correction), which were noninferior within the prespecified 2-hour upper margin, and the maternal satisfaction scores (11-point 0-10 numerical rating scale) with allocated labor care were 9 (interquartile range, 8-9) in the 8-hour arm and 8 (interquartile range, 7-9) in the 4-hour arm (P=.814). In addition, oxytocin infusion to birth interval difference was noninferior within the 97.5% confidence interval (-1.59 to 0.23) margin of 1.3 hours. Of the maternal outcomes, the amniotomy to first vaginal examination intervals were 3.9±1.8 hours in the 8-hour arm and 3.4±1.3 hours in the 4-hour arm (P=.026), and the numbers of vaginal examinations were 2.00 (interquartile range, 2.00-3.00) in the 8-hour arm and 3.00 (interquratile range, 2.00-3.25) in the 4-hour arm (P<.001). For the 8-hour arm, the first vaginal examination was less likely to be as scheduled and more likely to be indicated by sensation to bear down (P<.001), and the epidural analgesia rates were lower (13/102 participants [12.7%] in the 8-hour arm vs 28/102 participants [27.5%] in the 4-hour arm; relative risk, 0.46; 95% confidence interval, 0.26-0.84; P=.009). Other outcomes of the mode of delivery, indications for cesarean delivery, and delivery blood loss were not different. Neonatal outcomes were not different. CONCLUSION: Routine first vaginal examination at 8 hours compared with that at 4 hours was noninferior for the time to birth but did not improve maternal satisfaction.
Assuntos
Amniotomia , Maturidade Cervical , Trabalho de Parto Induzido , Ocitócicos , Ocitocina , Humanos , Feminino , Trabalho de Parto Induzido/métodos , Gravidez , Adulto , Amniotomia/métodos , Ocitócicos/administração & dosagem , Ocitocina/administração & dosagem , Maturidade Cervical/fisiologia , Maturidade Cervical/efeitos dos fármacos , Malásia , Fatores de Tempo , Paridade , Satisfação do PacienteRESUMO
OBJECTIVE: To compare the labor duration and other maternal and neonatal outcomes between hospitalized women with uncomplicated pregnancies receiving amniotomy at 5 cm cervical dilatation and those not receiving amniotomy. METHODS: This prospective, randomized controlled trial was conducted at a tertiary hospital between June 2020 and October 2021. The study included low-risk pregnant women with spontaneous onset of labor at term, carrying a single fetus in cephalic presentation and with intact amniotic membranes. When the cervical dilatation reached 5 cm, participants were randomly assigned to receive or not receive amniotomy. Maternal demographics, labor and delivery data, and neonatal outcomes were compared between the two groups. RESULTS: The amniotomy group had a significantly shorter duration of labor compared with the control group (mean difference 49.4 min, 95% confidence interval [CI] 16.8-81.9, P = 0.003). The following outcomes were not significantly different between the two groups: (1) the need for oxytocin to augment labor; (2) cesarean section rates; (3) the incidence rates of suspected fetal distress and instrumental delivery; and (4) neonatal outcomes. CONCLUSIONS: Compared with expectant management, amniotomy during the active phase of labor (as newly defined by WHO) can shorten the labor duration without an increased risk of cesarean delivery or other negative consequences. THAI CLINICAL TRIALS REGISTRY (TCTR) (TCTR20200522001): https://www.thaiclinicaltrials.org/show/TCTR20200522001.
Assuntos
Amniotomia , Cesárea , Recém-Nascido , Gravidez , Feminino , Humanos , Conduta Expectante , Estudos Prospectivos , Ocitocina , Organização Mundial da Saúde , Trabalho de Parto Induzido/efeitos adversosRESUMO
BACKGROUND: The optimal timing of amniotomy during labor induction is a topic of ongoing debate due to the potential risks associated with both amniotomy and prolonged labor. As such, individuals in the field of obstetrics and gynecology must carefully evaluate the associated benefits and drawbacks of this procedure. While amniotomy can expedite the labor process, it may also lead to complications such as umbilical cord prolapse, fetal distress, and infection. Therefore, a careful and thorough examination of the risks and benefits of amniotomy during labor induction is essential in making an informed decision regarding the optimal timing of this procedure. OBJECTIVE: This study aimed to determine if an amniotomy within 2 hours after Foley balloon removal reduced the duration of active labor and time taken to achieve vaginal delivery when compared with an amniotomy ≥4 hours after balloon removal among term pregnant women who underwent labor induction. STUDY DESIGN: This was an open-label, randomized controlled trial that was conducted at a single academic center from October 2020 to March 2023. Term participants who were eligible for preinduction cervical ripening with a Foley balloon were randomized into 2 groups, namely the early amniotomy (rupture of membranes within 2 hours after Foley balloon removal) and delayed amniotomy (rupture of membranes performed more than 4 hours after Foley balloon removal) groups. Randomization was stratified by parity. The primary outcome was time from Foley balloon insertion to active phase of labor. Secondary outcomes, including time to delivery, cesarean delivery rates, and maternal and neonatal complications, were analyzed using intention-to-treat and per-protocol analyses. RESULTS: Of the 150 participants who consented and were enrolled, 149 were included in the analysis. In the intention-to-treat population, an early amniotomy did not significantly shorten the time between Foley balloon insertion and active labor when compared with a delayed amniotomy (885 vs 975 minutes; P=.08). An early amniotomy was associated with a significantly shorter time from Foley balloon placement to active labor in nulliparous individuals (1211; 584-2340 vs 1585; 683-2760; P=.02). When evaluating the secondary outcomes, an early amniotomy was associated with a significantly shorter time to active labor onset (312.5 vs 442.5 minutes; P=.02) and delivery (484 vs 587 minutes; P=.03) from Foley balloon removal with a higher rate of delivery within 36 hours (96% vs 85%; P=.03). Individuals in the early amniotomy group reached active labor 1.5 times faster after Foley balloon insertion than those in the delayed group (hazard ratio, 1.5; 95% confidence interval, 1.1-2.2; P=.02). Those with an early amniotomy also reached vaginal delivery 1.5 times faster after Foley balloon removal than those in the delayed group (hazard ratio, 1.5; 95% confidence interval, 1-2.2; P=.03). A delayed amniotomy was associated with a higher rate of postpartum hemorrhage (0% vs 9.5%; P=.01). No significant differences were observed in the cesarean delivery rates, length of hospital stay, maternal infection, or neonatal outcomes. CONCLUSION: Although an early amniotomy does not shorten the time from Foley balloon insertion to active labor, it shortens time from Foley balloon removal to active labor and delivery without increasing complications. The increased postpartum hemorrhage rate in the delayed amniotomy group suggests increased risks with delayed amniotomy.
Assuntos
Amniotomia , Maturidade Cervical , Trabalho de Parto Induzido , Humanos , Feminino , Trabalho de Parto Induzido/métodos , Gravidez , Adulto , Amniotomia/métodos , Fatores de Tempo , Cateterismo/métodos , Parto Obstétrico/métodosRESUMO
Abstract Objectives: to identify the prevalence and factors associated with obstetric interventions in parturients assisted in public maternity hospitals. Methods: a cross-sectional study with 344 puerperal women, from two public maternity hospitals, referring to childbirth by Sistema Único de Saúde (SUS) (Public Health Service System) in Londrina City, Paraná, Brazil, between January and June 2017. The medical records were the data source. The following obstetric interventions were considered: oxytocin use, artificial rupture of the membranes, instrumental childbirth and episiotomy. Multivariate Poisson regression was used to analyze associated factors, with p<5% being significant. Results: the prevalence of obstetric intervention was 55.5%, the maximum number of interventions in the same parturient woman was three. The most frequent interventions were the use of oxytocin (50.0%) and artificial rupture of membranes (29.7%). The variables associated on maternal disease (p=0.005) and intrapartum meconium (p=0.022) independently increased, the risk of obstetric intervention, while dilation was equal to or greater than 5 cm at admission, there was a protective factor against this outcome (p=0.030). Conclusion: the prevalence of obstetric interventions was high. In the case of maternal disease and intrapartum meconium, special attention should be given to the parturient woman, in order to avoid unnecessary interventions. Thus, the maternity hospitals need to review their protocols, seeking good practices in childbirth care.
Resumo Objetivos: identificar a prevalência e os fatores associados a intervenções obstétricas em parturientes atendidas em maternidades públicas. Métodos: estudo transversal, com 344 puérperas, de duas maternidades públicas, referência ao parto pelo Sistema Único de Saúde no município de Londrina, Paraná, Brasil, entre janeiro e junho de 2017. Constituíram fonte de dados os prontuários hospitalares. As seguintes intervenções obstétricas foram consideradas: uso de ocitocina, rotura artificial das membranas, parto instrumental e realização de episiotomia. Para análise dos fatores associados utilizou-se a regressão multivariada de Poisson, sendo significativo p<5%. Resultados: a prevalência de intervenção obstétrica foi de 55,5%, o número máximo de intervenções em uma mesma parturiente foi três. As intervenções mais frequentes foram o uso de ocitocina (50,0%) e a rotura artificial das membranas (29,7%). As variáveis doença materna associada (p=0,005) e mecônio intraparto (p=0,022) aumentaram, de maneira independente, o risco de intervenção obstétrica, enquanto que a dilatação igual ou superior a 5 cm na internação constituiu fator de proteção a esse desfecho (p= 0,030). Conclusão: a prevalência de intervenções obstétricas foi elevada. Na vigência de doença materna e de mecônio intraparto, especial atenção deve ser dedicada à parturiente, para que sejam evitadas intervenções desnecessárias, assim as maternidades precisam rever seus protocolos, buscando as boas práticas de atenção ao parto.
Assuntos
Humanos , Feminino , Gravidez , Trabalho de Parto , Fatores de Risco , Medicalização , Tocologia , Parto Normal/estatística & dados numéricos , Cuidado Pré-Natal , Brasil , Ocitocina , Distribuição de Poisson , Estudos Transversais , Episiotomia , Amniotomia , MaternidadesRESUMO
Abstract Objectives: To characterize the practices used by nurse-midwives in a Natural Birth Center (NBC) and to verify the maternal and neonatal outcomes. Method: This was a cross-sectional, documentary, retrospective study with a quantitative approach in which the medical records of 300 parturients who gave birth in a state hospital in the city of São Paulo were analyzed. The categories of the World Health Organization (WHO) composed the criteria adopted for the analysis of the obstetric practices. Fisher's exact test or the likelihood ratio and Student t-test were used. Results: The nurse-midwives mostly used category A practices of the WHO. There were no statistically significant associations between practices and perineal outcomes. There was a statistically significant association between the weight of the newborn and the number of neonatal complications, as well as between the delivery position of the primiparous women and clavicle fractures of the newborns. Conclusion and Implications for the practice: Evidence-based practices were followed by the nurse-midwives in the NBC analyzed. The maternal and neonatal outcomes were adequate. There is a need to improve care in the second stage of the delivery in order to avoid behaviors that reflect in neonatal complications. The study makes it possible to reflect on the importance of the continuous evaluation of the care provided.
Resumen Objetivos: Caracterizar las prácticas utilizadas por las enfermeras obstetras en un Centro de Parto Normal (CPN) y verificar los resultados maternos y neonatales. Método: Estudio transversal, documental, retrospectivo, con abordaje cuantitativo, en el cual fueron analizados prontuarios de 300 parturientas que dieron a luz en hospital público de la ciudad de São Paulo. Los criterios adoptados para el análisis de las prácticas obstétricas fueron las categorías de la Organización Mundial de la Salud (OMS). Fueron utilizadas las pruebas, exacto de Fisher o razón de verosimilitud (Likelihood Ratio) y t-Student. Resultados: Las enfermeras obstetras utilizaron mayoritariamente las prácticas de la categoría A de la OMS. No hubo diferencia estadísticamente significativa en las asociaciones entre las prácticas y los resultados perineales. Se observó una diferencia estadísticamente significativa entre el peso del recién nacido y el número de intercurrencias neonatales, así como entre las posiciones de parto de las primíparas con la fractura de clavícula de los recién nacidos. Conclusión e Implicaciones para la práctica: Las prácticas basadas en evidencias son seguidas por las enfermeras obstetras en el CPN analizado. Los resultados maternos y neonatales se mostraron adecuados. Es necesario mejorar la asistencia en el segundo período del parto para evitar conductas que reflejen en las interacciones neonatales. El estudio posibilita la reflexión sobre la importancia de la evaluación continuada de la asistencia prestada.
Resumo Objetivos: Caracterizar as práticas utilizadas pelas enfermeiras obstetras em um Centro de Parto Normal (CPN) e verificar os desfechos maternos e neonatais. Método: Estudo transversal, documental, retrospectivo, com abordagem quantitativa. Analisaram-se prontuários de 300 parturientes que deram à luz em hospital estadual da cidade de São Paulo. Os critérios adotados para a análise das práticas obstétricas foram as categorias da Organização Mundial da Saúde (OMS). Utilizaram-se os testes exatos de Fisher ou razão de verossimilhança (Likelihood Ratio) e t-Student. Resultados: As enfermeiras obstetras utilizaram majoritariamente as práticas da categoria A da OMS. Não houve diferença estatisticamente significativa nas associações entre as práticas e os desfechos perineais. Houve diferença estatisticamente significativa entre o peso do recém-nascido e o número de intercorrências neonatais e entre as posições de parto das primíparas com a fratura de clavícula dos recém-nascidos. Conclusão e Implicações para a prática: As práticas baseadas em evidências são seguidas pelas enfermeiras obstetras no CPN analisado. Os desfechos maternos e neonatais mostraram-se adequados. Há necessidade de melhorar a assistência no segundo período do parto, evitando condutas que reflitam em intercorrências neonatais. O estudo possibilita a reflexão sobre a importância da avaliação continuada da assistência prestada.
Assuntos
Humanos , Feminino , Gravidez , Adolescente , Adulto , Tocologia/estatística & dados numéricos , Parto Normal/enfermagem , Enfermeiros Obstétricos , Enfermagem Obstétrica/estatística & dados numéricos , Períneo/lesões , Aleitamento Materno , Ocitocina/uso terapêutico , Cardiotocografia , Prontuários Médicos , Estudos Transversais , Estudos Retrospectivos , Caminhada , Clavícula/lesões , Episiotomia , Enfermagem Baseada em Evidências/estatística & dados numéricos , Amniotomia , Parto Normal/estatística & dados numéricosRESUMO
The labour induction is an intervention to initiate artificially the uterine contractions to produce the effacement and dilatation of the uterine cervix until the child-birth is achieved. It is indicated when the benefit of the termination of the pregnancy for the mother and the child is greater than its continuation. It is perfored in more or less the 20 % of the women. In our institution the rate oscillates in around the 9 % of the cases. It is understand as an successful induction the termination of the labour through the vaginal delivery. The methods for labour induction more commonly used at present are mechanical and pharmacological. Between the first group we can find the Hamilton maneuver and the amniotomy. And between the pharmacologicals we find the oxytocine. These elements are considered in the article
Assuntos
Humanos , Feminino , Gravidez , Contração Uterina , Primeira Fase do Trabalho de Parto , Ocitocina/farmacologia , Colo do Útero/embriologia , Cesárea , Maturidade Cervical , Parto , Amniotomia/métodos , Trabalho de Parto Induzido/métodosRESUMO
Há diversas publicações científicas evidenciando os benefícios do atendimento humanizado ao parto vaginal. Assim mesmo, os profissionais mais resistentes à readequação de suas tradicionais condutas são os médicos. Por isso, realizou-se uma revisão de literatura com objetivo de avaliar quais as melhores condutas a serem adotadas pelos Obstetras, nos partos em que forem responsáveis pelo atendimento. Os principais tópicos pesquisados foram as intervenções médicas diretas ou prescricionais. Avaliou-se a prescrição de dieta, permissão de acompanhante e doula, posição da parturiente, realização de amniotomia e episiotomia, e o clampeamento do cordão umbilical. Deve-se permitir a ingesta líquida e de alimentos leves e incentivar a participação de acompanhantes e doulas. Recomenda-se ainda a adoção de posições verticalizadas, o uso da amniotomia e da episiotomia somente em casos selecionados e o clampeamento tardio do cordão umbilical. Os resultados, em geral, apontam para uma diminuição de intervenções, respeitando os desejos das mulheres, sem abandonar a vigilância do bem-estar fetal.(AU)
There are several scientific publications demonstrating the benefits of humanized childbirth care. However, the most resistant professionals to readjust their traditional behaviors are physicians. Therefore, we carried out a literature review to evaluate what are the best measures to be adopted by Obstetricians in births that they are responsible for. The main topics studied were the direct or prescriptive medical interventions. It has been assessed diet prescription, companion and doula permission, labour's positioning, amniotomy and episiotomy performing and umbilical cord clamping. Liquids and food intake should be allowed and the participation of companions and doulas should be encouraged. It is also recommended the adoption of upright positions, selective use of amniotomy and episiotomy and late umbilical cord clamping. The results generally indicates interventions declining, in respect of women desires, without abandoning the fetal well-being surveillance.(AU)
Assuntos
Humanos , Feminino , Gravidez , Trabalho de Parto/psicologia , Parto Humanizado , Brasil , Bases de Dados Bibliográficas , Episiotomia , Posicionamento do Paciente/métodos , Doulas , Amniotomia , Clampeamento do Cordão UmbilicalRESUMO
RESUMO O objetivo foi analisar a assistência ao parto de adolescentes primigestas no contexto do Sistema Único de Saúde (SUS) no município de Cuiabá, Mato Grosso. Estudo transversal, descritivo e documental com amostragem aleatória simples composta por 164 prontuários de puérperas adolescentes coletados por meio de ficha estruturada durante os meses de dezembro de 2012 a maio de 2013. Foi realizada análise descritiva simples dos dados. Os resultados indicaram que o parto cesáreo apresentou taxa de 37,2%, a amniotomia foi adotada em 62,1%, a ocitocina em 53,4% e a episiotomia em 82,4%. A desproporção céfalo-pélvica representou 27,9% das indicações de cesariana e dentre as complicações maternas, a hemorragia destacou-se em ambos os tipos de parto. Conclui-se a existência de uma forte influência do modelo tecnicista sobre os resultados maternos na assistência obstétrica de adolescentes primigestas e que o fato do desconhecimento atrelado à vulnerabilidade deste grupo populacional evidencia a soberania do profissional em relação às decisões obstétricas.
RESUMEN El objetivo ha sido analizar la atención al parto de adolescentes primigestas en el contexto del Sistema Único de Salud (SUS) en el municipio de Cuiabá, Mato Grosso. Estudio transversal, descriptivo y documental con muestreo aleatorio simple compuesto de 164 registros médicos de puérperas adolescentes recogidos a través del formulario estructurado durante los meses de diciembre de 2012 hasta mayo de 2013. Fue realizado el análisis descriptivo simple de los datos. Los resultados indicaron que el parto por cesárea ha presentado tasa de 37,2%, la amniotomía fue adoptada en 62,1%, la oxitocina en 53,4% y la episiotomía en 82,4%. La desproporción cefalopélvica ha representado 27,9% de las indicaciones de la cesárea y entre las complicaciones maternas, la hemorragia se ha destacado en ambos tipos de parto. Se concluye que existe una fuerte influencia del modelo técnico sobre los resultados maternos en la atención obstétrica a las adolescentes primigestas y que el hecho del desconocimiento relacionado a la vulnerabilidad de este grupo poblacional evidencia la soberanía del profesional en relación a las decisiones obstétricas.
ABSTRACT It aimed to analyze labor assistance for primigravida adolescents in the context of the Unified Health System (SUS) in the city of Cuiabá, Mato Grosso. Cross-sectional, descriptive and documental study with a random sample composed of 164 medical records of postpartum adolescent collected through structured file during the months of December 2012 to May 2013. Data were analyzed through simple descriptive analysis. The results indicated that cesarean section showed rate of 37.2%, amniotomy was adopted in 62.1%, oxytocin 53.4% and 82.4% in the episiotomy. Cephalopelvic disproportion represented 27.9% of cesarean section indications and among maternal complications, hemorrhage stood out in both types of delivery. It is concluded that there is a strong influence of the technicist model on maternal outcomes in obstetric care to pregnant adolescents and that the lack of knowledge linked to the vulnerability of this group shows the professional sovereignty in relation to obstetric decisions.
Assuntos
Humanos , Feminino , Adolescente , Gravidez na Adolescência/estatística & dados numéricos , Cuidado Pré-Natal/normas , Trabalho de Parto/psicologia , Parto Humanizado , Enfermagem Obstétrica/normas , Procedimentos Cirúrgicos Operatórios/enfermagem , Sistema Único de Saúde/normas , Cesárea/estatística & dados numéricos , Parto Obstétrico/estatística & dados numéricos , Episiotomia/enfermagem , Desproporção Cefalopélvica/enfermagem , Período Periparto/psicologia , Amniotomia/métodos , Hemorragia Pós-Parto/cirurgia , Tocologia/métodos , Parto Normal/estatística & dados numéricos , Enfermeiros Obstétricos/educaçãoRESUMO
Se realizó un estudio prospectivo, longitudinal y de intervención, de las 90 gestantes con fase latente prolongada del trabajo de parto, a partir de ocho horas, atendidas en el Servicio de Perinatología del Hospital "Mariana Grajales Coello" y "Juan Bruno Zayas Alfonso" de Santiago de Cuba, en el período 2011-2013, con el objetivo de demostrar la utilidad del tratamiento activo con rotura artificial de membrana tardía, empleado en la fase latente prolongada del trabajo de parto. Se obtuvo que el tiempo promedio para alcanzar la fase activa después de iniciada la conducción fue de 5,08 horas y 80,3 % de las mujeres tuvieron respuesta rápida; mientras que la duración de la fase activa fue de 4,05 horas como promedio. Se demostró la utilidad del nuevo protocolo terapéutico para la distocia de fase latente.
A prospective, longitudinal intervention study, of the 90 pregnant women with prolonged latent phase of labor, from eight hours on, assisted in the Perinatology Service of "Mariana Grajales Coello" and "Juan Bruno Zayas Alfonso" Hospitals in Santiago de Cuba was carried out in the period 2011-2013, with the objective of demonstrating the usefulness of the active treatment with late artificial rupture of membrane, used in the prolonged latent phase of labor. It was obtained that the average time to reach the active phase after initiating the induction was of 5,08 hours and 80,3% of the women had a fast response; while the duration of the active phase was of 4,05 hours as average. The usefulness of the new therapeutic protocol for the dystocia of latent phase was demonstrated.