Marcos Nakamura-Pereira

Obstetric interventions during labor and childbirth in Brazilian low-risk women

This study evaluated the use of best practices (eating, movement, use of nonpharmacological methods for pain relief and partograph) and obstetric interventions in labor and delivery among low-risk women. Data from the hospital-based survey Birth in Brazil conducted between 2011 and 2012 was used. Best practices during labor occurred in less than 50% of women and prevalence of the use of these practices was lower in the North, Northeast and Central West Regions. The rate of use of oxytocin drips and amniotomy was 40%, and was higher among women admitted to public hospitals and in women with a low level of education. The uterine fundal pressure, episiotomy and lithotomy were used in 37%, 56% and 92% of women, respectively. Caesarean section rates were lower in women using the public health system, nonwhites, women with a low level of education and multiparous women. To improve the health of mothers and newborns and promote quality of life, a change of approach to labor and childbirth that focuses on evidence-based care is required in both the public and private health sectors.Este artigo avaliou o uso das boas praticas (alimentacao, deambulacao, uso de metodos nao farmacologicos para alivio da dor e de partograma) e de intervencoes obstetricas na assistencia ao trabalho de parto e parto de mulheres de risco obstetrico habitual. Foram utilizados dados da pesquisa Nascer no Brasil, estudo de base hospitalar realizada em 2011/2012, com entrevistas de 23.894 mulheres. As boas praticas durante o trabalho de parto ocorreram em menos de 50% das mulheres, sendo menos frequentes nas regioes Norte, Nordeste e Centro-oeste. O uso de ocitocina e amniotomia foi de 40%, sendo maior no setor publico e nas mulheres com menor escolaridade. A manobra de Kristeller, episiotomia e litotomia foram utilizada, em 37%, 56% e 92% das mulheres, respectivamente. A cesariana foi menos frequente nas usuarias do setor publico, nao brancas, com menor escolaridade e multiparas. Para melhorar a saude de maes e criancas e promover a qualidade de vida, o Sistema Unico de Saude (SUS) e, sobretudo o setor privado, necessitam mudar o modelo de atencao obstetrica promovendo um cuidado baseado em evidencias cientificas.

Processo de decisão pelo tipo de parto no Brasil: da preferência inicial das mulheres à via de parto final

El proposito de este articulo es describir los factores de preferencia en el tipo de parto durante el embarazo temprano, y estudiar el proceso de decision en la opcion de parto en Brasil. Los datos de una cohorte de base hospitalaria nacional, con 23.894 mujeres, durante el periodo 2011-2012, se analizaron de acuerdo a la fuente de los fondos para el parto y la paridad, mediante la prueba de χ2. La preferencia inicial por cesarea fue de un 27,6%, desde el 15,4% (sector publico primiparas) al 73,2% (sector privado multiparas con cesarea). La principal razon para la eleccion de parto vaginal era la mejor recuperacion de este tipo de parto (68,5%), y para la cesarea, el temor al dolor durante el parto (46,6%). La experiencia positiva con el parto vaginal (28,7%); parto por cesarea (24,5%) y la esterilizacion femenina (32.3%) fueron citados por multiparas. Las mujeres en el sector privado tuvieron un 87,5% de cesarea con una mayor decision hacia este tipo de parto a finales del embarazo, independientemente del diagnostico de las complicaciones. En ambos sectores, la proporcion de la cesarea fue mucho mayor de lo deseado.The purpose of this article is to describe the factors cited for the preference for type of birth in early pregnancy and reconstruct the decision process by type of birth in Brazil. Data from a national hospital-based cohort with 23,940 postpartum women, held in 2011-2012, were analyzed according to source of funding for birth and parity, using the χ2 test. The initial preference for cesarean delivery was 27.6%, ranging from 15.4% (primiparous public sector) to 73.2% (multiparous women with previous cesarean private sector). The main reason for the choice of vaginal delivery was the best recovery of this type of birth (68.5%) and for the choice of cesarean, the fear of pain (46.6%). Positive experience with vaginal delivery (28.7%), cesarean delivery (24.5%) and perform female sterilization (32.3%) were cited by multiparous. Women from private sector presented 87.5% caesarean, with increased decision for cesarean birth in end of gestation, independent of diagnosis of complications. In both sectors, the proportion of caesarean section was much higher than desired by women.O objetivo deste artigo e descrever os fatores referidos para a preferencia pelo tipo de parto no inicio da gestacao e reconstruir o processo de decisao pelo tipo de parto no Brasil. Dados de uma coorte de base hospitalar nacional com 23.940 puerperas, realizada em 2011-2012, foram analisados, segundo fonte de pagamento do parto e paridade, com utilizacao do teste χ2. A preferencia inicial pela cesariana foi de 27,6%, variando de 15,4% (primiparas no setor publico) a 73,2% (multiparas com cesariana anterior no setor privado). O principal motivo para a escolha do parto vaginal foi a melhor recuperacao desse tipo de parto (68,5%) e para a cesariana o medo da dor do parto (46,6%). Experiencia positiva com parto vaginal (28,7%), parto cesareo (24,5%) e realizacao de laqueadura tubaria (32,3%) foram citadas por multiparas. Mulheres do setor privado apresentaram 87,5% de cesariana, com aumento da decisao pelo parto cesareo no final da gestacao, independentemente do diagnostico de complicacoes. Em ambos os setores, a proporcao de cesariana foi muito superior ao desejado pelas mulheres.

Prenatal diagnosis of pentalogy of cantrell in the first trimester: is 3-dimensional sonography needed?

We report the prenatal diagnosis of 2 cases of Pentalogy of Cantrell in the first trimester. In case 1, sonographic evaluation revealed ectopia cordis, omphalocele, and cystic hygroma at 10 weeks gestation. In case 2, sonographic assessment during the first trimester detected ectopia cordis and omphalocele at 11 weeks gestation. In both cases, the patient opted for elective pregnancy termination, and Pentalogy of Cantrell was confirmed in 2 male fetuses. We discuss the role of Doppler imaging and 3‐dimensional sonography as complementary methods to conventional sonographic assessment of abdominal wall defects at early pregnancy.

Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual

This study evaluated the use of best practices (eating, movement, use of nonpharmacological methods for pain relief and partograph) and obstetric interventions in labor and delivery among low-risk women. Data from the hospital-based survey Birth in Brazil conducted between 2011 and 2012 was used. Best practices during labor occurred in less than 50% of women and prevalence of the use of these practices was lower in the North, Northeast and Central West Regions. The rate of use of oxytocin drips and amniotomy was 40%, and was higher among women admitted to public hospitals and in women with a low level of education. The uterine fundal pressure, episiotomy and lithotomy were used in 37%, 56% and 92% of women, respectively. Caesarean section rates were lower in women using the public health system, nonwhites, women with a low level of education and multiparous women. To improve the health of mothers and newborns and promote quality of life, a change of approach to labor and childbirth that focuses on evidence-based care is required in both the public and private health sectors.Este artigo avaliou o uso das boas praticas (alimentacao, deambulacao, uso de metodos nao farmacologicos para alivio da dor e de partograma) e de intervencoes obstetricas na assistencia ao trabalho de parto e parto de mulheres de risco obstetrico habitual. Foram utilizados dados da pesquisa Nascer no Brasil, estudo de base hospitalar realizada em 2011/2012, com entrevistas de 23.894 mulheres. As boas praticas durante o trabalho de parto ocorreram em menos de 50% das mulheres, sendo menos frequentes nas regioes Norte, Nordeste e Centro-oeste. O uso de ocitocina e amniotomia foi de 40%, sendo maior no setor publico e nas mulheres com menor escolaridade. A manobra de Kristeller, episiotomia e litotomia foram utilizada, em 37%, 56% e 92% das mulheres, respectivamente. A cesariana foi menos frequente nas usuarias do setor publico, nao brancas, com menor escolaridade e multiparas. Para melhorar a saude de maes e criancas e promover a qualidade de vida, o Sistema Unico de Saude (SUS) e, sobretudo o setor privado, necessitam mudar o modelo de atencao obstetrica promovendo um cuidado baseado em evidencias cientificas.

Process of decision-making regarding the mode of birth in Brazil: from the initial preference of women to the final mode of birth

El proposito de este articulo es describir los factores de preferencia en el tipo de parto durante el embarazo temprano, y estudiar el proceso de decision en la opcion de parto en Brasil. Los datos de una cohorte de base hospitalaria nacional, con 23.894 mujeres, durante el periodo 2011-2012, se analizaron de acuerdo a la fuente de los fondos para el parto y la paridad, mediante la prueba de χ2. La preferencia inicial por cesarea fue de un 27,6%, desde el 15,4% (sector publico primiparas) al 73,2% (sector privado multiparas con cesarea). La principal razon para la eleccion de parto vaginal era la mejor recuperacion de este tipo de parto (68,5%), y para la cesarea, el temor al dolor durante el parto (46,6%). La experiencia positiva con el parto vaginal (28,7%); parto por cesarea (24,5%) y la esterilizacion femenina (32.3%) fueron citados por multiparas. Las mujeres en el sector privado tuvieron un 87,5% de cesarea con una mayor decision hacia este tipo de parto a finales del embarazo, independientemente del diagnostico de las complicaciones. En ambos sectores, la proporcion de la cesarea fue mucho mayor de lo deseado.The purpose of this article is to describe the factors cited for the preference for type of birth in early pregnancy and reconstruct the decision process by type of birth in Brazil. Data from a national hospital-based cohort with 23,940 postpartum women, held in 2011-2012, were analyzed according to source of funding for birth and parity, using the χ2 test. The initial preference for cesarean delivery was 27.6%, ranging from 15.4% (primiparous public sector) to 73.2% (multiparous women with previous cesarean private sector). The main reason for the choice of vaginal delivery was the best recovery of this type of birth (68.5%) and for the choice of cesarean, the fear of pain (46.6%). Positive experience with vaginal delivery (28.7%), cesarean delivery (24.5%) and perform female sterilization (32.3%) were cited by multiparous. Women from private sector presented 87.5% caesarean, with increased decision for cesarean birth in end of gestation, independent of diagnosis of complications. In both sectors, the proportion of caesarean section was much higher than desired by women.O objetivo deste artigo e descrever os fatores referidos para a preferencia pelo tipo de parto no inicio da gestacao e reconstruir o processo de decisao pelo tipo de parto no Brasil. Dados de uma coorte de base hospitalar nacional com 23.940 puerperas, realizada em 2011-2012, foram analisados, segundo fonte de pagamento do parto e paridade, com utilizacao do teste χ2. A preferencia inicial pela cesariana foi de 27,6%, variando de 15,4% (primiparas no setor publico) a 73,2% (multiparas com cesariana anterior no setor privado). O principal motivo para a escolha do parto vaginal foi a melhor recuperacao desse tipo de parto (68,5%) e para a cesariana o medo da dor do parto (46,6%). Experiencia positiva com parto vaginal (28,7%), parto cesareo (24,5%) e realizacao de laqueadura tubaria (32,3%) foram citadas por multiparas. Mulheres do setor privado apresentaram 87,5% de cesariana, com aumento da decisao pelo parto cesareo no final da gestacao, independentemente do diagnostico de complicacoes. Em ambos os setores, a proporcao de cesariana foi muito superior ao desejado pelas mulheres.

Use of Robson classification to assess cesarean section rate in Brazil: the role of source of payment for childbirth

BackgroundCesarean section (CS) rates are increasing worldwide but there is some concern with this trend because of potential maternal and perinatal risks. The Robson classification is the standard method to monitor and compare CS rates. Our objective was to analyze CS rates in Brazil according to source of payment for childbirth (public or private) using the Robson classification.MethodsData are from the 2011–2012 “Birth in Brazil” study, which used a national hospital-based sample of 23,940 women. We categorized all women into Robson groups and reported the relative size of each Robson group, the CS rate in each group and the absolute and relative contributions made by each to the overall CS rate. Differences were analyzed through chi-square and Z-test with a significance level ofu2009<u20090.05.ResultsThe overall CS rate in Brazil was 51.9xa0% (42.9xa0% in the public and 87.9xa0% in the private health sector). The Robson groups with the highest impact on Brazil’s CS rate in both public and private sectors were group 2 (nulliparous, term, cephalic with induced or cesarean delivery before labor), group 5 (multiparous, term, cephalic presentation and previous cesarean section) and group 10 (cephalic preterm pregnancies), which accounted for more than 70xa0% of CS carried out in the country. High-risk women had significantly greater CS rates compared with low-risk women in almost all Robson groups in the public sector only.ConclusionsPublic policies should be directed at reducing CS in nulliparous women, particularly by reducing the number of elective CS in these women, and encouraging vaginal birth after cesarean to reduce repeat CS in multiparous women.

Incidence of maternal near miss in hospital childbirth and postpartum: data from the Birth in Brazil study

This study evaluated data on the incidence of maternal near miss identified on World Health Organization (WHO) criteria from the Birth in Brazil survey. The study was conducted between February 2011 and October 2012. The results presented are estimates for the study population (2,337,476 births), based on a sample of 23,894 women interviewed. The results showed an incidence of maternal near miss of 10.21 per 1,000 live births and a near-miss-to-mortality ratio of 30.8 maternal near miss to every maternal death. Maternal near miss was identified most prevalently by clinical criteria, at incidence of 5.2 per 1,000 live births. Maternal near miss was associated with maternal age 35 or more years (RR=1.6; 95%CI: 1.1-2.5), a history of previous cesarean delivery (RR=1.9; 95%CI: 1.1-3.4) and high-risk pregnancy (RR=4.5; 95%CI: 2.8-7.0). incidence of maternal near miss was also higher at hospitals in capital cities (RR=2.2; 95%CI: 1.3-3.8) and those belonging to Brazils national health service, the Brazilian Unified National Health System (SUS) (RR=3.2; 95%CI: 1.6-6.6). Improved quality of childbirth care services can help reduce maternal mortality in Brazil.Este estudo avaliou os dados sobre a incidencia do near miss materno, identificados segundo os criterios da Organizacao Mundial da Saude, na pesquisa Nascer no Brasil. O estudo foi realizado entre fevereiro/2011 e outubro/2012 e os resultados apresentados sao estimativas para a populacao estudada (2.337.476 partos), baseados na amostra de 23.894 puerperas entrevistadas. Os resultados mostraram uma incidencia de near miss materno de 10,21 por mil nascidos vivos e uma razao de mortalidade do near miss materno de 30,8 casos para cada morte materna. Os criterios clinicos para identificacao do near miss materno foram os mais prevalentes e tiveram incidencia de 5,2 por mil nascidos vivos. O near miss materno esteve associado com a idade materna de 35 anos ou mais (RR = 1,6; IC95%: 1,1-2,5), com historia de cesariana anterior (RR = 1,9; IC95%: 1,1-3,4) e gestacao de risco (RR = 4,5; IC95%: 2,8-7,0). Os hospitais localizados nas capitais (RR = 2,2; IC95%: 1,3-3,8) e os pertencentes ao SUS (RR = 3,2; IC95%: 1,6-6,6) tambem apresentaram maior incidencia de casos de near miss materno. A qualificacao dos servicos de assistencia ao parto pode ajudar a reduzir a mortalidade materna no Brasil.

Comparing different diagnostic approaches to severe maternal morbidity and near-miss: a pilot study in a Brazilian tertiary hospital

OBJECTIVEnDespite recent guidelines proposed by the World Health Organization (WHO), the operational definition of maternal near-miss (MNM) is still heterogeneous. This study aimed at evaluating the pros and cons of three instruments in characterizing MNM cases. The performance of two of the three instruments was also investigated vis-à-vis the WHO criteria.nnnSTUDY DESIGNnA retrospective chart review study was carried out in a tertiary maternity hospital in Rio de Janeiro, Brazil. The medical records of 1163 obstetric hospital admissions from January to December 2008 were reviewed. Cases were first classified as positive or otherwise according to the WHO, Waterstone and literature-based criteria. A descriptive analysis was then carried out focusing on divergent classifications. Finally, diagnostic properties of the Waterstone and the literature-based criteria were calculated taking the WHO criteria as reference standard.nnnRESULTSnThere were eight maternal deaths, 157 cases classified as positive by at least one of the three approaches and 998 cases without severe morbidities. Twenty-seven cases of MNM were detected according to the WHO criteria, whereas the Waterstone and the literature-based criteria identified 123 and 153 cases, respectively. Among the 130 cases identified as negative by the WHO criteria and positive by the Waterstone or literature-based criteria, 119 presented hypertensive disorders (91.5%). Additionally, four cases were identified exclusively by the WHO criteria because of acute thrombocytopenia (platelets<50,000). Estimates of sensitivity, specificity, accuracy and negative predictive values were all above 75% for the Waterstone and literature-based approaches, but both criteria presented positive predictive values (PPV) below 60% even with high magnitudes of MNM.nnnCONCLUSIONnThese results underline that different approaches entail heterogeneous estimates of MNM. The Waterstone and the literature-based criteria are not suitable for a definitive diagnosis of MNM in view of their low PPV, but they seem adequate as a first approach in investigating MNM. While negative results by both alternative criteria virtually rule out MNM, a positive result would require a reassessment using the WHO criteria to confirm the diagnosis of maternal near-miss.

Caesarean Delivery and Postpartum Maternal Mortality: A Population-Based Case Control Study in Brazil.

Background Cesarean delivery rates continue to increase worldwide and reached 57% in Brazil in 2014. Although the safety of this surgery has improved in the last decades, this trend is a concern because it carries potential risks to women’s health and may be a modifiable risk factor of maternal mortality. This paper aims to investigate the risk of postpartum maternal death directly associated with cesarean delivery in comparison to vaginal delivery in Brazil. Methods This was a population-based case—control study performed in eight Brazilian states. To control for indication bias, deaths due to antenatal morbidity were excluded. We included 73 cases of postpartum maternal deaths from 2009–2012. Controls were selected from the Birth in Brazil Study, a 2011 nationwide survey including 9,221 postpartum women. We examined the association of cesarean section and postpartum maternal death by multivariate logistic regression, adjusting for confounders. Results After controlling for indication bias and confounders, the risk of postpartum maternal death was almost three-fold higher with cesarean than vaginal delivery (OR 2.87, 95% CI 1.63–5.06), mainly due to deaths from postpartum hemorrhage and complications of anesthesia. Conclusion Cesarean delivery is an independent risk factor of postpartum maternal death. Clinicians and patients should consider this fact in balancing the benefits and risks of the procedure.

Prevalence and risk factors related to preterm birth in Brazil.

BackgroundThe rate of preterm birth has been increasing worldwide, including in Brazil. This constitutes a significant public health challenge because of the higher levels of morbidity and mortality and long-term health effects associated with preterm birth. This study describes and quantifies factors affecting spontaneous and provider-initiated preterm birth in Brazil.MethodsData are from the 2011–2012 “Birth in Brazil” study, which used a national population-based sample of 23,940 women. We analyzed the variables following a three-level hierarchical methodology. For each level, we performed non-conditional multiple logistic regression for both spontaneous and provider-initiated preterm birth.ResultsThe rate of preterm birth was 11.5 %ufeff, (95 % confidence 10.3 % to 12.9 %) 60.7xa0% spontaneous - with spontaneous onset of labor or premature preterm rupture of membranes - and 39.3xa0% provider-initiated, with more than 90xa0% of the last group being pre-labor cesarean deliveries. Socio-demographic factors associated with spontaneous preterm birth were adolescent pregnancy, low total years of schooling, and inadequate prenatal care. Other risk factors were previous preterm birth (OR 3.74; 95xa0% CI 2.92–4.79), multiple pregnancy (OR 16.42; 95xa0% CI 10.56–25.53), abruptio placentae (OR 2.38; 95xa0% CI 1.27–4.47) and infections (OR 4.89; 95xa0% CI 1.72–13.88). In contrast, provider-initiated preterm birth was associated with private childbirth healthcare (OR 1.47; 95xa0% CI 1.09–1.97), advanced-age pregnancy (OR 1.27; 95xa0% CI 1.01–1.59), two or more prior cesarean deliveries (OR 1.64; 95xa0% CI 1.19–2.26), multiple pregnancy (OR 20.29; 95xa0% CI 12.58–32.72) and any maternal or fetal pathology (OR 6.84; 95xa0% CI 5.56–8.42).ConclusionThe high proportion of provider-initiated preterm birth and its association with prior cesarean deliveries and all of the studied maternal/fetal pathologies suggest that a reduction of this type of prematurity may be possible. The association of spontaneous preterm birth with socially-disadvantaged groups reaffirms that the reduction of social and health inequalities should continue to be a national priority.