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1.
BMJ Case Rep ; 14(1)2021 Jan 26.
Artigo em Inglês | MEDLINE | ID: mdl-33500293

RESUMO

A complete perineal wound breakdown of a fourth degree laceration leading to a cloaca is a rare but devastating complication of vaginal childbirth. A 32-year-old primiparous woman presented with an obstetric cloaca 4 months following delivery. She underwent preoperative evaluation and, following extensive counselling, elected to proceed with operative repair. The procedure is presented in 15 well-defined steps with photos. The repair was performed in standard fashion with three supplementary steps. These included: (1) division of the rectovaginal tissue into three distinct layers; (2) attachment of these layers individually to the reconstructed perineal body and sphincter and (3) incorporation of the levator muscles into the repair. The wound healed well within 6 weeks of repair. Now 3½ years postoperatively, the patient has no faecal incontinence or sexual dysfunction and only minimal defecatory dysfunction. The discussion describes our surgical approach in the context of a review of the literature.


Assuntos
Canal Anal/cirurgia , Cicatriz/cirurgia , Lacerações/cirurgia , Complicações do Trabalho de Parto/cirurgia , Períneo/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Deiscência da Ferida Operatória/cirurgia , Vagina/cirurgia , Adulto , Canal Anal/lesões , Parto Obstétrico , Incontinência Fecal , Feminino , Humanos , Lacerações/fisiopatologia , Complicações do Trabalho de Parto/fisiopatologia , Períneo/lesões , Gravidez , Deiscência da Ferida Operatória/fisiopatologia , Vagina/lesões
2.
Obstet Gynecol ; 136(4): e81-e89, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32976379

RESUMO

There are three broad categories of hemostatic agents: 1) caustic, 2) physical, and 3) biologic. Because of the paucity of data on the use of topical hemostatic agents in gynecologic and obstetric surgery, indications for use are extrapolated from data on the use of these agents in other types of surgeries and are based on expert opinion. Topical hemostatic agents can be a useful adjunct to assist in the management of intraoperative bleeding in select circumstances. Topical hemostatic agents most commonly are used in situations where the use of electrocautery or sutures for hemostatic control of surgical bleeding is not ideal or safe, including bleeding in areas with nearby vulnerable structures or in the presence of diffuse bleeding from peritoneal surfaces or cut surfaces of solid organs. When managing intraoperative bleeding, there is no substitute for meticulous surgical technique. When possible, the surgeon should attempt to control intraoperative bleeding with sutures, clips, or electrosurgery before the use of hemostatic agents. It is essential for surgeons to understand the appropriate use, contraindications, and cost of these agents in order to make the most informed decision for patient care.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Procedimentos Cirúrgicos em Ginecologia/métodos , Hemostasia Cirúrgica/métodos , Hemostáticos , Complicações do Trabalho de Parto/cirurgia , Administração Tópica , Adolescente , Tomada de Decisão Clínica , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Hemostáticos/classificação , Hemostáticos/uso terapêutico , Humanos , Cuidados Intraoperatórios/métodos , Seleção de Pacientes , Padrões de Prática Médica , Gravidez
3.
Obstet Gynecol ; 136(4): 870-871, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32976377

RESUMO

There are three broad categories of hemostatic agents: 1) caustic, 2) physical, and 3) biologic. Because of the paucity of data on the use of topical hemostatic agents in gynecologic and obstetric surgery, indications for use are extrapolated from data on the use of these agents in other types of surgeries and are based on expert opinion. Topical hemostatic agents can be a useful adjunct to assist in the management of intraoperative bleeding in select circumstances. Topical hemostatic agents most commonly are used in situations where the use of electrocautery or sutures for hemostatic control of surgical bleeding is not ideal or safe, including bleeding in areas with nearby vulnerable structures or in the presence of diffuse bleeding from peritoneal surfaces or cut surfaces of solid organs. When managing intraoperative bleeding, there is no substitute for meticulous surgical technique. When possible, the surgeon should attempt to control intraoperative bleeding with sutures, clips, or electrosurgery before the use of hemostatic agents. It is essential for surgeons to understand the appropriate use, contraindications, and cost of these agents in order to make the most informed decision for patient care.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Procedimentos Cirúrgicos em Ginecologia/métodos , Hemostasia Cirúrgica/métodos , Hemostáticos , Complicações do Trabalho de Parto/cirurgia , Administração Tópica , Adolescente , Tomada de Decisão Clínica , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Hemostáticos/classificação , Hemostáticos/uso terapêutico , Humanos , Cuidados Intraoperatórios/métodos , Seleção de Pacientes , Padrões de Prática Médica , Gravidez
4.
Tokai J Exp Clin Med ; 45(3): 131-135, 2020 Sep 20.
Artigo em Inglês | MEDLINE | ID: mdl-32901901

RESUMO

Retained products of conception (RPOC) refer to the persistence of placental or fetal tissue in the uterus following delivery or miscarriage. RPOC may cause massive postpartum or post-abortion hemorrhage. Arterial embolization (AE) is an effective choice of management for postpartum hemorrhage including RPOC. We report a case of hemorrhagic RPOC, in which uterine artery embolization with transcervical resection did not achieve hemostasis, and laparotomy with uterine compression sutures was subsequently required. The RPOC was apparently fed by an aberrant branch derived from the inferior mesenteric artery (IMA). AE of IMA was not performed because of possible necrosis of the descending colon and rectum. A physician should be aware that AE is not an all-encompassing hemostatic technique for postpartum bleeding, such as with RPOC, and should keep alternatives in mind.


Assuntos
Hemostasia Cirúrgica/métodos , Laparotomia/métodos , Artéria Mesentérica Inferior , Complicações do Trabalho de Parto/etiologia , Complicações do Trabalho de Parto/cirurgia , Placenta Retida/cirurgia , Hemorragia Pós-Parto/etiologia , Hemorragia Pós-Parto/cirurgia , Técnicas de Sutura , Útero/cirurgia , Adulto , Colo/patologia , Contraindicações , Feminino , Humanos , Angiografia por Ressonância Magnética , Necrose , Complicações do Trabalho de Parto/diagnóstico por imagem , Placenta Retida/diagnóstico por imagem , Hemorragia Pós-Parto/diagnóstico por imagem , Gravidez , Reto/patologia , Tomografia Computadorizada por Raios X , Embolização da Artéria Uterina/efeitos adversos
5.
Medisur ; 18(4): 726-732, jul.-ago. 2020. graf
Artigo em Espanhol | LILACS | ID: biblio-1125256

RESUMO

RESUMEN El embarazo es un proceso natural que debe concebirse sin complicaciones; sin embargo, los desenlaces obstétricos fatales en gestaciones previas, son marcadores importantes de un riesgo incrementado de morbimortalidad materna y perinatal en los próximos embarazos. La hemorragia obstétrica posparto es una de las más frecuentes y severas complicaciones del periparto; como una alternativa terapéutica útil en esos casos, el manejo quirúrgico conservador de útero permite mantener la fertilidad en mujeres con paridad no satisfecha, y mejorar su calidad de vida, aunque en muchas ocasiones, por causas diversas, esto no es posible. Se presenta el caso de una paciente de 26 años de edad, con historia obstétrica de tres embarazos, un parto y un aborto (provocado); y el antecedente de complicación obstétrica hemorrágica en embarazo anterior por atonía uterina, la cual requirió tratamiento quirúrgico conservador con técnicas combinadas (suturas compresivas de Hayman, Ho-Cho y ligadura bilateral de las arterias uterinas). Dos años después, acudió a los servicios obstétricos con gestación de 16 semanas (alto riesgo obstétrico). Este artículo tiene el objetivo de exponer el informe de una paciente en la que se logró la concepción de un embarazo posterior a la realización de cirugía conservadora del útero.


ABSTRACT Pregnancy is a natural process that must be conceived without complications; however, fatal obstetric outcomes in previous pregnancies are important markers of an increased risk of maternal and perinatal morbidity and mortality in future pregnancies. Postpartum obstetric hemorrhage is one of the most frequent and severe complications of the peripartum; As a useful therapeutic alternative in these cases, conservative surgical management of the uterus allows fertility to be maintained in women with unsatisfied parity, and improves their quality of life, although in many cases, for various reasons, this is not possible. The case of a 26-year-old patient is presented, with an obstetric history of three pregnancies, one delivery and one abortion (provoked); and a history of hemorrhagic obstetric complication in previous pregnancy due to uterine atony, which required conservative surgical treatment with combined techniques (Hayman, Ho-Cho compression sutures and bilateral ligation of the uterine arteries). Two years later, she attended obstetric services with a 16-week gestation (high obstetric risk). This article aims to present the report of a patient in whom the conception of a pregnancy was achieved after performing conservative surgery on the uterus.


Assuntos
Humanos , Feminino , Útero/cirurgia , Indicadores de Morbimortalidade , Hemorragia Pós-Parto/cirurgia , Complicações do Trabalho de Parto , Complicações do Trabalho de Parto/cirurgia
6.
Arch Gynecol Obstet ; 302(2): 321-328, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32564129

RESUMO

PURPOSE: Antibiotic treatment during surgical repair of obstetric anal sphincter injuries (OASIS) had been a matter of debate. We aimed to review the available literature regarding the efficacy of metronidazole administration in women undergoing perineal repair following obstetric OASIS. STUDY DESIGN: To identify potentially eligible studies, we searched PubMed, Scopus, Embase and the Cochrane Library from inception to January 13th, 2019.Reference lists of identified studies were searched. No language restrictions were applied. We used a combination of keywords and text words represented by "Metronidazole", "obstetrics", "obstetric anal sphincter injury", "OASIS", "third degree tear", "fourth degree tear", "third degree laceration", "fourth degree laceration", "antibiotic therapy", "perineal damage" and "perineal trauma". Two reviewers independently screened the titles and abstracts of records retrieved from the database searches. Both reviewers recommended studies for the full-text review. Thescreen of full-text articles recommended by at least one reviewer was done independently by the same two reviewers and assessedfor inclusion in the systematic review. Disagreements between reviewers were resolved by consensus. RESULTS: The electronic database search yielded a total of 54,356 results (Fig. 1). After duplicate exclusion 28,154 references remained. Of them, 26 were relevant to the review based on title and abstract screening. None of these articles dealt with the use of metronidazole for the prevention of infections complicating anal sphincter repair in women with OASIS. A Cochrane review addressing antibiotic prophylaxis for patients following OASIS, compared prophylactic antibiotics against placebo or no antibiotics, included only one randomized controlled trial of 147 participants. This study showed that prophylactic antibiotics (not metronidazole) may be helpful to prevent perineal wound complications following OASIS. Fig. 1 Study seection process CONCLUSION: Anaerobic infections potentially complicate wound repair after OASIS. Although scientific societies recommend the use of antibiotics for the prevention of infectious morbidity after OASIS, no study has specifically assessed the role of metronidazole.


Assuntos
Canal Anal/lesões , Antibacterianos/uso terapêutico , Lacerações/etiologia , Metronidazol/uso terapêutico , Períneo/lesões , Infecção dos Ferimentos/prevenção & controle , Ferimentos e Lesões/prevenção & controle , Adulto , Canal Anal/microbiologia , Antibioticoprofilaxia/efeitos adversos , Parto Obstétrico/métodos , Feminino , Humanos , Complicações do Trabalho de Parto/cirurgia , Obstetrícia/métodos , Gravidez , Ferimentos e Lesões/complicações , Ferimentos e Lesões/tratamento farmacológico
7.
Arch Gynecol Obstet ; 302(1): 77-83, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32388778

RESUMO

PURPOSE: To evaluate the impact of a selective use of episiotomy combined with Couder's maneuver on the incidence of perineal tears in spontaneous term deliveries. METHODS: A comparative, retrospective, mono-centric study in a university maternity unit was designed and included all primiparous women who delivered spontaneously after 37 weeks of gestation in cephalic presentation. Two cohorts were studied, before and after the practice of Couder's maneuver. In the first cohort, the ''OSE cohort'' only selective episiotomies were performed from January 2009 to December 2010. In the second cohort, from January 2016 to December 2017, the ''SEC cohort'' selective episiotomies combined with Couder's maneuver were performed by midwives and obstetricians. The primary outcome was the type of perineal tears, according to the Royal College of Obstetricians and Gynaecologists (RCOG) classification. RESULTS: A total of 2081 patients were included: 909 patients in the OSE cohort and 1172 patients in the SEC cohort. Couder's maneuver was performed in 59% of the SEC cohort. In the SEC cohort, there were an increase in the number of intact perinea (55% versus 63%, p < 0.001), a decrease in second-degree perineal tears (18% versus 11%, p < 0.001) and a decrease in labia minora tears (48% versus 37%, p < 0.001). The rate of obstetrical anal sphincter injuries was less than 1% in both cohorts (0.3% versus 0.5%, p = 0.7). CONCLUSION: A selective use of episiotomy combined with Couder's maneuver could reduce the incidence of perineal tears, particularly second-degree perineal tears, without increasing the rate of obstetrical anal sphincter injuries.


Assuntos
Canal Anal/lesões , Parto Obstétrico/efeitos adversos , Episiotomia/estatística & dados numéricos , Lacerações/epidemiologia , Complicações do Trabalho de Parto/cirurgia , Períneo/lesões , Adulto , Parto Obstétrico/métodos , Episiotomia/efeitos adversos , Feminino , Humanos , Incidência , Tocologia , Complicações do Trabalho de Parto/epidemiologia , Avaliação de Processos e Resultados em Cuidados de Saúde , Paridade , Períneo/cirurgia , Médicos , Gravidez , Resultado da Gravidez , Estudos Retrospectivos
8.
Am J Obstet Gynecol ; 222(6): 580.e1-580.e5, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32142829

RESUMO

Obstetric anal sphincter injuries represent the minority of obstetric lacerations, but can have a significant long-term impact on urinary and fecal continence, as well as pelvic organ support. Accurate diagnosis of lacerations, appropriate repair, and close follow-up are essential to healthy healing and to improve outcomes for women. The infrequency of these injuries has resulted in a lack of familiarity with laceration repair and postpartum care of this population at all levels of practice. As such, continuing education strategies aimed at simulation, increased clinical exposure to anal sphincter injuries, and evidence-based repair techniques are important for mitigating the deficits in the current obstetric environment. Ensuring that patients have access to timely multidisciplinary postpartum care and education on the laceration incurred is essential to promote healthy healing and to optimize pelvic floor outcomes.


Assuntos
Canal Anal/lesões , Competência Clínica , Lacerações/diagnóstico , Lacerações/cirurgia , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/cirurgia , Obstetrícia/educação , Parto Obstétrico/métodos , Episiotomia , Incontinência Fecal , Feminino , Humanos , Diafragma da Pelve/lesões , Períneo/lesões , Cuidado Pós-Natal , Gravidez , Fístula Retovaginal , Treinamento por Simulação
9.
BJOG ; 127(7): 897-904, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31961472

RESUMO

OBJECTIVE: To describe and compare baseline renal anatomy and renal function in patients with obstetric fistulas, and to evaluate whether preoperative renal testing and imaging may aid with operative decision making. DESIGN: A prospective cohort study. SETTING: Fistula Care Centre in Malawi. POPULATION: Women with an obstetric fistula. METHODS: Baseline creatinine testing and renal ultrasounds were performed. Surgeons completed a short questionnaire on the usefulness of creatinine and renal ultrasound on operative decision making. MAIN OUTCOME MEASURES: Baseline creatinine and renal ultrasound findings. RESULTS: Four surgeons performed operations on 85 patients. The mean creatinine in patients with vesicovaginal fistulas (VVF) was 0.60 ng/ml versus patients with uretero-vaginal fistulas (UVF) (0.79 ng/ml, P = 0.012). When a grade 3 or more hydronephrosis is absent on renal ultrasound, the negative predictive value of the presence of UVF is 93.3% (95% confidence interval [CI] 88.6-96.2) with a specificity of 97.2% (95% CI 90.3-99.6). In cases of UVF, surgeons found the renal ultrasound results useful or very useful 87.5% of the time, and the creatinine useful or very useful 75% of the time. CONCLUSION: In this pilot study, most patients with obstetric fistulas presented with a normal creatinine. In the absence of a grade 3 hydronephrosis or above on renal ultrasound, the probability of not having a UVF is 93.3%. Surgeons should consider performing preoperative renal ultrasound testing in all patients with an obstetric fistula, particularly in women with a prior laparotomy, as this population has risk factors for ureterovaginal fistula. TWEETABLE ABSTRACT: Most patients with obstetric fistulas have normal renal function. Preoperative renal ultrasounds should be performed.


Assuntos
Rim/diagnóstico por imagem , Complicações do Trabalho de Parto , Fístula Urinária , Fístula Vesicovaginal , Adulto , Feminino , Humanos , Testes de Função Renal/métodos , Malaui/epidemiologia , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/epidemiologia , Complicações do Trabalho de Parto/cirurgia , Avaliação de Processos e Resultados em Cuidados de Saúde , Gravidez , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/normas , Estudos Prospectivos , Melhoria de Qualidade , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos , Ultrassonografia/métodos , Fístula Urinária/diagnóstico , Fístula Urinária/epidemiologia , Fístula Urinária/etiologia , Fístula Urinária/cirurgia , Fístula Vesicovaginal/epidemiologia , Fístula Vesicovaginal/etiologia , Fístula Vesicovaginal/cirurgia
11.
J Matern Fetal Neonatal Med ; 33(6): 1064-1071, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30107755

RESUMO

Background: Perineal trauma is a common problem that may affect women during vaginal delivery; this trauma can be either spontaneous (tear) or intentional (episiotomy). When repair of perineal trauma is required, adequate analgesics must be obtained. Topical products as lidocaine-prilocaine (EMLA) cream is one of the suggested methods, but still there is lack of evidence with regard to its efficacy and safety.Objective: The aim of this review is to assess the evidence of utilizing EMLA cream in comparison to local perineal infiltration anesthesia for pain control during perineal repair after vaginal delivery.Data sources: Medline, Embase, Dynamed Plus, ScienceDirect, TRIP database, ClinicalTrials.gov and the Cochrane Library were searched electronically from January 2006 to May 2018 for studies investigating the effect of lidocaine-prilocaine cream in relieving pain during repair of perineal trauma.Methods of study selection: All randomized controlled trials assessing effect of lidocaine-prilocaine cream versus local infiltration anesthesia in relieving pain during repair of perineal trauma were considered for this meta-analysis. Fifteen studies were identified of which four studies deemed eligible for this review. Quality and risk of bias assessment was performed for all studies.Data extraction: Two researchers independently extracted the data from the individual articles and entered into RevMan software. The weighted mean difference (WMD) and 95% confidence interval (CI) was calculated. Statistical heterogeneity between studies was assessed by the Higgins chi-square and (I2) statistics. When heterogeneity was significant, a random-effects model was used for meta-analysis. Otherwise, the fixed effect meta-analysis was used when there was no significant heterogeneity.Results: Pooled analysis of result in "pain score" was insignificant between the two groups (WMD -1.11; 95% CI (-2.55 to 0.33); p = .13). Furthermore, the use of additional analgesia showed no statistically significant difference between the two groups (WMD 1.34; 95% CI (0.66-2.71), p = .42). Regarding patient satisfaction, an overall analysis of three studies showed significant results favoring EMLA cream group users (WMD 4.65; 95% CI (1.96-11.03), p = .0005). The pooled analysis of the outcome "duration of repair" showed the significantly shorter duration of repair in EMLA cream users (n = 92) than local infiltration anesthesia (n = 95) (1.72 min; 95% CI (-2.76 to -0.67), p = .001).Conclusions: This meta-analysis suggests that topical lidocaine-prilocaine cream gives comparable results in reducing pain during perineal repair after vaginal delivery.


Assuntos
Anestesia Local/métodos , Anestésicos Locais/administração & dosagem , Lacerações/cirurgia , Combinação Lidocaína e Prilocaína/administração & dosagem , Complicações do Trabalho de Parto/cirurgia , Períneo/lesões , Feminino , Humanos , Pomadas , Períneo/cirurgia , Gravidez , Resultado do Tratamento
12.
Eur J Obstet Gynecol Reprod Biol ; 245: 73-76, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31881374

RESUMO

OBJECTIVE: To evaluate if newborn weight difference is associated with the mode of delivery in women with a previous cesarean section due to arrest of descent. STUDY DESIGN: This retrospective cohort analysis included all women admitted to the delivery room of Carmel Medical Center with a singleton fetus at vertex presentation and a prior cesarean section for arrest of descent. A comparison was made between women who had a subsequent successful vaginal birth after cesarean delivery vs. a repeat cesarean section for arrest of descent. The primary outcome was newborn weight difference between the previous cesarean section and the present delivery. Secondary outcomes were gestational age, gravidity, age, induction of labor, previous vaginal birth and epidural analgesia. RESULTS: Of 179 women with a prior cesarean section due to arrest of descent, 55 women (30.7 %) underwent an elective repeat cesarean section. Of the remaining 124 women, 95 women (76.6 %) achieved a vaginal delivery. Out of the 29 cases who underwent a repeat cesarean section, 18 women had a cesarean section for arrest of descent. Women who achieved vaginal delivery were more likely to be with higher gravidity, a previous vaginal delivery and a lower rate of epidural anesthesia. Following multivariate logistic regression, the women who required a cesarean section due to arrest of descent, had significantly higher birth weight in the current than in the previous pregnancy, compared to women achieving vaginal delivery (Odds Ratio 4.7, CI 95 % 1.4-15.7, P = 0.012). CONCLUSION: Current birth weight higher than the previous newborn weight in a cesarean section for arrest of descent is associated with lower likelihood of successful vaginal birth after cesarean delivery and therefore should be taken in consideration during fetal weight estimation and the decision on the mode of delivery. This issue should be explored in future prospective large-cohort studies.


Assuntos
Peso ao Nascer , Recesariana/estatística & dados numéricos , Parto Obstétrico/estatística & dados numéricos , Complicações do Trabalho de Parto/cirurgia , Nascimento Vaginal Após Cesárea/estatística & dados numéricos , Adulto , Parto Obstétrico/métodos , Feminino , Peso Fetal , Humanos , Recém-Nascido , Israel , Modelos Logísticos , Complicações do Trabalho de Parto/etiologia , Gravidez , Estudos Retrospectivos , Prova de Trabalho de Parto , Vagina
13.
Am J Perinatol ; 37(5): 503-510, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-30895577

RESUMO

OBJECTIVE: This study aimed to evaluate whether the number of vacuum pop-offs, the number of forceps pulls, or the duration of operative vaginal delivery (OVD) is associated with adverse maternal and perinatal outcomes. STUDY DESIGN: This is a secondary analysis of a multicenter observational cohort of women who underwent an attempted OVD. Women were stratified by the duration of OVD and the number of pop-offs (vacuum) or pulls (forceps) attempted. Severe perineal lacerations, failed OVD, and a composite adverse neonatal outcome were compared by the duration of OVD and number of pop-offs or pulls. RESULTS: Of the 115,502 women in the primary cohort, 5,325 (4.6%) underwent an attempt at OVD: 3,594 (67.5%) with vacuum and 1,731 (32.5%) with forceps. After adjusting for potential confounders, an increasing number of pop-offs was associated with an increased odds of the composite adverse neonatal outcome. However, an increasing duration of vacuum exhibited a stronger association with the composite adverse neonatal outcome. Similarly, the number of forceps pulls was less strongly associated with the composite adverse neonatal outcome compared with the duration of forceps application. CONCLUSION: The duration of OVD may be more associated with adverse neonatal outcomes than the number of pop-offs or pulls.


Assuntos
Extração Obstétrica/efeitos adversos , Complicações do Trabalho de Parto/cirurgia , Duração da Cirurgia , Adulto , Extração Obstétrica/instrumentação , Feminino , Humanos , Recém-Nascido , Doenças do Recém-Nascido/etiologia , Lacerações/etiologia , Forceps Obstétrico/efeitos adversos , Gravidez , Falha de Tratamento , Vácuo-Extração/efeitos adversos
14.
Am J Obstet Gynecol ; 222(1): 71.e1-71.e6, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31336076

RESUMO

BACKGROUND: Because nearly one-third of births in the United States are now achieved by cesarean delivery, comprising more than 1.27 million women each year, national organizations have recently published revised guidelines for the management of labor. These new guidelines stipulate that labor arrest should not be diagnosed unless ≥6 cm cervical dilatation has been reached or labor has been stimulated for at ≥6 hours. OBJECTIVE: To determine the cervical dilatation and hours of labor stimulation prior to cesarean delivery for arrest of dilatation. MATERIALS AND METHODS: Between January 1, 1999, andDecember 31, 2000, a prospective observational study of all primary cesarean deliveries was conducted at 13 university centers comprising the Eunice Kennedy Shriver National Institute for Child Health and Human Development, Maternal-Fetal Medicine Units Network. This secondary analysis includes all live-born, singleton, nonanomalous, cephalic gestations delivered by primary cesarean delivery at ≥37 weeks. A cesarean delivery was considered to have been performed for arrest of dilatation if the indication for the procedure was failure to progress, cephalopelvic disproportion, or failed induction. Augmentation was defined as stimulation after spontaneous labor had been previously diagnosed. Analysis included both the latent and active phases of labor. The active phase of labor was diagnosed when cervical dilatation was ≥4 cm in the presence of uterine contractions. RESULTS: A total of 13,269 primary cesarean deliveries were available for analysis, 8,546 (65%) of which were performed for inadequate progress of labor with cervical dilatation recorded at the time of cesarean delivery. Of these cesarean deliveries for labor arrest, a total of 719 (8%) were performed in the latent phase of labor and 7827 (92%) were performed when cervical dilatation was ≥4 cm (active phase). Approximately two-thirds (n = =5876; 69%) received intrauterine pressure monitoring. A total of 5636 women (66% of those reaching the active phase of labor) had reached ≥6 cm cervical dilatation before cesarean delivery was performed. Moreover, 7440 (95%) of the 7827 women in active labor had ≥6 cm dilatation or had received labor stimulation ≥6 hours prior to cesarean delivery for arrest of dilatation. CONCLUSION: Women undergoing primary cesarean delivery for arrest of dilatation 15 years before the recommendations of the Obstetrics Care Consensus had received bona fide efforts to achieve adequate labor consistent with the recommendations of the Consensus. Because 95% of these women had ≥6 cm dilatation or had received labor stimulation ≥6 hours prior to cesarean delivery for arrest of dilatation, these new recommendations are unlikely to change the cesarean delivery rates.


Assuntos
Cesárea/estatística & dados numéricos , Complicações do Trabalho de Parto/cirurgia , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Desproporção Cefalopélvica/cirurgia , Feminino , Humanos , Primeira Fase do Trabalho de Parto , Trabalho de Parto Induzido/estatística & dados numéricos , Complicações do Trabalho de Parto/diagnóstico , Guias de Prática Clínica como Assunto , Gravidez , Estudos Prospectivos , Adulto Jovem
15.
BMC Pregnancy Childbirth ; 19(1): 499, 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31842788

RESUMO

BACKGROUND: The technique used in the repair of a perineal injury resulting from childbirth could avoid discomfort and morbidity during the postpartum period. Recent studies show inconsistent results and support the need for new research with the inclusion of new health parameters not yet studied. Therefore, this study aims to evaluate if the suture technique (continuous or interrupted) has an effect on pain and other postpartum problems, incidence of incontinence (urinary and/or fecal), and the restart of sexual relations. METHODS: A single-blind randomized clinical trial was conducted in five hospitals in south-east Spain. The participants were primiparous women who had experienced a perineal injury during delivery (second-degree tear or episiotomy). Data was collected on sociodemographic variables, variables associated with pregnancy, labor and delivery, and the postpartum period, and outcomes during the 3 months after delivery: pain, incontinence, and restart of sexual relations. Odds ratios (OR) were calculated by binary logistic regression to assess the influence of the suture type on binary outcomes and t-test used for comparing continuous outcomes. Multivariate analyses (using logistic regression -adjusted (aOR)- and analysis of covariance) were carried out to adjust for unbalanced variables after randomization. RESULTS: A total of 70 women were included in the intervention group (continuous suture) and 64 in the reference group (interrupted sutures). A negative association was observed (aOR = 0.39; 95% CI = 0.18-0.86) between a continuous suture and the need for analgesia at 24 h postpartum. Pain experienced by the women at 24 h postpartum was assessed as 4.4 ± 0.3 compared with a score of 3.4 ± 0.3 in the group with continuous sutures (p = 0.011). At 15 days postpartum, women in the intervention group experienced less pain (aOR = 0.38; 95% CI = 0.18-0.80) (p = 0.019). Urinary sphincter incontinence was also evaluated at 15 days, with 4.3% (n = 3) of the women in the intervention group presenting with urinary incontinence compared with 18.8% (n = 12) in the control group (aOR = 0.11; 95% CI = 0.03-0.47) (P = 0.003). CONCLUSIONS: The women who had a continuous suture repair showed lower levels of pain from delivery to 3 months after delivery and had a lower incidence of urinary incontinence at 15 days postpartum. TRIAL REGISTRATION: ClinicalTrials.gov NCT03825211 posted January 31, 2019 (retrospectively registered).


Assuntos
Lacerações/cirurgia , Complicações do Trabalho de Parto/cirurgia , Períneo/lesões , Complicações Pós-Operatórias/etiologia , Técnicas de Sutura/efeitos adversos , Adulto , Parto Obstétrico/efeitos adversos , Episiotomia/efeitos adversos , Feminino , Humanos , Lacerações/etiologia , Períneo/cirurgia , Período Pós-Parto , Gravidez , Método Simples-Cego , Espanha , Resultado do Tratamento , Adulto Jovem
16.
Semin Fetal Neonatal Med ; 24(6): 101045, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31727572

RESUMO

Newborn emergencies that occur in the delivery room are frequently the result of life-threatening congenital anomalies that can result in death or severe disability if not treated in the immediate postnatal period. Prompt recognition and treatment of such disorders are paramount to ensuring the wellbeing of the infant. As congenital anomalies are frequently being diagnosed earlier due to improved prenatal detection, the coordination of planned interventions for life-threatening malformations is also becoming more common. This article serves as a guide for the presentation and initial management of the most common non-cardiac, newborn surgical emergencies.


Assuntos
Anormalidades Congênitas/cirurgia , Salas de Parto , Tratamento de Emergência/métodos , Complicações do Trabalho de Parto/cirurgia , Procedimentos Cirúrgicos Operatórios/métodos , Anormalidades Congênitas/diagnóstico , Intervenção Médica Precoce/métodos , Feminino , Humanos , Recém-Nascido , Complicações do Trabalho de Parto/diagnóstico , Gravidez , Diagnóstico Pré-Natal/métodos , Tempo para o Tratamento
17.
BMJ Open ; 9(10): e027991, 2019 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-31619418

RESUMO

INTRODUCTION: Female genital fistula is a debilitating traumatic injury, largely birth-associated, globally affecting up to 2 million women, mostly in sub-Saharan Africa. Fistula has significant physical, psychological and economic consequences. Women often face challenges in reintegrating and resuming prior roles despite successful surgery. Synthesising the evidence on services adjunct to fistula surgery and their outcomes is important for developing the evidence base for best practices and identifying research priorities. This scoping review seeks to examine the range of rehabilitation and reintegration services provided as adjunct to genital fistula surgery, map the existing programming and outcomes, and identify areas for additional research. METHODS AND ANALYSIS: Our scoping review is informed by existing methodological frameworks and will be conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-ScR guidelines. The search strategy will be applied to nine biomedical, public health and social science databases. The initial search was completed on 27 September 2018. Grey literature will be identified through targeted Google searches and from organisational websites identified as relevant by the United Nations Population Fund (UNFPA) Campaign to End Fistula. We will iteratively build our search strategy through term harvesting and review, and search reference lists of reports and articles to identify additional studies. Two reviewers will independently screen titles and abstracts, followed by full-text screening of all potentially relevant articles and standardised data extraction. Articles eligible for inclusion will discuss research or programmatic efforts around service provision in adjunct to surgery among females with genital fistula. Data will be presented in summary tables accompanied by narrative description. ETHICS AND DISSEMINATION: Ethics approval is not required for a scoping review. Our results can be used to inform policy, serve as support for funding and development of reintegration programmes and highlight areas for subsequent research. Results will be disseminated at relevant conferences and published in a peer-reviewed journal.


Assuntos
Complicações do Trabalho de Parto/cirurgia , Fístula Vaginal/reabilitação , Fístula Vaginal/cirurgia , Incontinência Fecal/etiologia , Incontinência Fecal/psicologia , Feminino , Humanos , Infertilidade Feminina/etiologia , Infertilidade Feminina/psicologia , Dor/etiologia , Dor/psicologia , Gravidez , Projetos de Pesquisa , Literatura de Revisão como Assunto , Estigma Social , Incontinência Urinária/etiologia , Incontinência Urinária/psicologia , Fístula Vaginal/psicologia
18.
Birth ; 46(4): 638-647, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31512773

RESUMO

BACKGROUND: The Unmet Obstetric Need (UON) indicator has been widely used to estimate unmet need for life-saving surgery at birth; however, its assumptions have not been verified. The objective of this study was to test two UON assumptions: (a) Absolute maternal indications (AMIs) require surgery for survival and (b) 1%-2% of deliveries develop AMIs, implying that rates of surgeries for AMIs below this threshold indicate excess mortality from these complications. METHODS: We used linked hospital and population-based data in central Ghana. Among hospital deliveries, we calculated the percentage of deliveries with AMIs who received surgery, and mortality among AMIs who did not. At the population level, we assessed whether the percentage of deliveries with surgeries for AMIs was inversely associated with mortality from these complications, stratified by education. RESULTS: A total of 380 of 387 (98%) hospital deliveries with recorded AMIs received surgery; an additional eight women with no AMI diagnosis died of AMI-related causes. Among the 50 148 deliveries in the population, surgeries for AMIs increased from 0.6% among women with no education to 1.9% among women with post-secondary education (P < .001). However, there was no association between AMI-related mortality and education (P = .546). Estimated AMI prevalence was 0.84% (95% CI: 0.76%-0.92%), below the assumed 1% minimum threshold. DISCUSSION: Obstetric providers consider AMIs absolute indications for surgery. However, low rates of surgeries for AMIs among less educated women were not associated with higher mortality. The UON indicator should be used with caution in estimating the unmet need for life-saving obstetric surgery; innovative approaches are needed to identify unmet need in the context of rising cesarean rates.


Assuntos
Cesárea/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde , Complicações do Trabalho de Parto/cirurgia , Adolescente , Adulto , Estudos Transversais , Escolaridade , Feminino , Gana/epidemiologia , Humanos , Mortalidade Materna , Pessoa de Meia-Idade , Complicações do Trabalho de Parto/epidemiologia , Gravidez , Adulto Jovem
19.
BMC Pregnancy Childbirth ; 19(1): 330, 2019 Sep 09.
Artigo em Inglês | MEDLINE | ID: mdl-31500581

RESUMO

BACKGROUND: In a recent population-based study we reported excess risk of neonatal mortality associated with vaginal breech delivery. In this case-control study we examine whether deviations from Norwegian guidelines are more common in breech deliveries resulting in intrapartum or neonatal deaths than in breech deliveries where the offspring survives, and if these deaths are potentially avoidable. MATERIAL AND METHODS: Case-control study completed as a perinatal audit including term breech deliveries of singleton without congenital anomalies in Norway from 1999 to 2015. Deliveries where the child died intrapartum or in the neonatal period were case deliveries. For each case, two control deliveries who survived were identified. All the included deliveries were reviewed by four obstetricians independently assessing if the deaths in the case group might have been avoided and if the management of the deviations from Norwegian guidelines were more common in case than in control deliveries. RESULTS: Thirty-one case and 62 control deliveries were identified by the Medical Birth Registry of Norway. After exclusion of non-eligible deliveries, 22 case and 31 control deliveries were studied. Three case and two control deliveries were unplanned home deliveries, while all in-hospital deliveries were in line with national guidelines. Antenatal care and/or management of in-hospital deliveries was assessed as suboptimal in seven (37%) case and two (7%) control deliveries (p = 0.020). Three case deliveries were completed as planned caesarean delivery and 12 (75%) of the remaining 16 deaths were considered potentially avoidable had planned caesarean delivery been done. In seven of these 16 deliveries, death was associated with cord prolapse or difficult delivery of the head. CONCLUSION: All in-hospital breech deliveries were in line with Norwegian guidelines. Seven of twelve potentially avoidable deaths were associated with birth complications related to breech presentation. However, suboptimal care was more common in case than control deliveries. Further improvement of intrapartum care may be obtained through continuous rigorous training and feedback from repeated perinatal audits.


Assuntos
Apresentação Pélvica , Cesárea , Parto Obstétrico , Complicações do Trabalho de Parto , Morte Perinatal/prevenção & controle , Cuidado Pré-Natal , Adulto , Estudos de Casos e Controles , Cesárea/métodos , Cesárea/estatística & dados numéricos , Parto Obstétrico/métodos , Parto Obstétrico/normas , Parto Obstétrico/estatística & dados numéricos , Feminino , Fidelidade a Diretrizes , Humanos , Recém-Nascido , Determinação de Necessidades de Cuidados de Saúde , Noruega/epidemiologia , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/etiologia , Complicações do Trabalho de Parto/mortalidade , Complicações do Trabalho de Parto/cirurgia , Mortalidade Perinatal , Guias de Prática Clínica como Assunto , Gravidez , Resultado da Gravidez/epidemiologia , Cuidado Pré-Natal/métodos , Cuidado Pré-Natal/normas , Melhoria de Qualidade
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