Maria Luiza Gonzalez Riesco

Risk factors for birth‐related perineal trauma: a cross‐sectional study in a birth centre

AIM AND OBJECTIVES To identify maternal, newborn and obstetric factors associated with birth-related perineal trauma in one independent birth centre. BACKGROUND Risk factors for birth-related perineal trauma include episiotomy, maternal age, ethnicity, parity and interventions during labour including use of oxytocin, maternal position at time of birth and infant birth weight. Understanding more about these factors could support the management of vaginal birth to prevent spontaneous perineal trauma, in line with initiatives to reduce routine use of episiotomy. DESIGN Cross-sectional study. METHODS Data were retrospectively collected from one independent birth centre in Brazil, during 2006-2009. The dependent variable (perineal trauma) was classified as: (1) intact perineum or first-degree laceration, (2) second-degree laceration and (3) episiotomy (right mediolateral or median). RESULTS There were 1079 births during the study period. Parity, use of oxytocin during labour, position at time of giving birth and infant birth weight were associated with second-degree lacerations and episiotomies. After adjusting for parity, oxytocin, maternal position at the expulsive stage of labour and infant birth weight influenced perineal outcomes among primiparae only. CONCLUSIONS Although the overall rate of episiotomies in this study was low compared with national data, it was observed that younger women were most vulnerable to this intervention. In this age group in particular, the use of oxytocin as well as semi-upright positions at the time of birth was associated with second-degree lacerations and episiotomies. RELEVANCE TO CLINICAL PRACTICE The use of upright alternative positions for birth and avoidance of use of oxytocin could reduce the risk of perineal trauma from lacerations and need to perform episiotomy.

Tipo de parto: expectativas das mulheres

This descriptive and exploratory study was carried out through interviews with 221 puerperal women who gave birth in Sao Paulo State public maternities located within the capital. The purposes of the work were: 1. to identify the type of childbirth women expected to have--whether vaginal births or cesareans--and why; 2. to verify to what extent womens expectations corresponded to the type of birth they had; 3. to compare medical indications for c-sections with womens understanding of justifications they were given for this intervention. Data revealed that 74.7% of the women expected to have vaginal births and 25.3% expected to have cesarean sections. Vaginal birth, expected by 165 interviewees, occurred in 66.1% of these cases. Among women who expected having vaginal births, the most mentioned justification was that recuperation afterwards was faster. Among women who expected cesareans, the most mentioned justification was a previous c-section. The justifications presented by 61 women for having been submitted to c-sections did not coincide with medical indications for this intervention in 47.5% of the cases.Estudo descritivo e exploratorio, realizado mediante entrevista com 221 puerperas que tiveram parto em maternidades publicas estaduais, localizadas no municipio de Sao Paulo. Teve como objetivos: 1. identificar o tipo de parto esperado pelas mulheres, considerando a via vaginal ou cesariana, e sua justificativa; 2. verificar a ocorrencia do tipo de parto, segundo as expectativas dessas mulheres; 3. comparar a indicacao medica da cesariana com o entendimento das mulheres sobre justificativa dessa intervencao. Os dados revelam que 74,7% tinham expectativa de que o parto fosse normal, e 25,3%, de que fosse cesarea. O parto normal, esperado por 165 entrevistadas, ocorreu em 66,1% dessas mulheres. A justificativa mais citada pelas mulheres para esperar o parto normal foi a recuperacao pos-parto mais rapida e, para a cesarea, ter tido cesarea anterior. As justificativas apresentadas por 61 mulheres para a realizacao da cesariana nao era coincidente com a indicacao medica em 47,5% dos casos.

Women's experiences of perineal pain during the immediate postnatal period: A cross-sectional study in Brazil

OBJECTIVE To identify the severity and prevalence of perineal pain during the post partum in-patient period and associated obstetric, maternal and newborn baby factors following birth. DESIGN Cross-sectional study. SETTING A postnatal ward of a hospital in São Paulo, Brazil. PARTICIPANTS 303 Postnatal women. MEASUREMENTS Interviews and perineal assessment were conducted to evaluate the perineal outcomes (trauma and pain). Data on maternal characteristics and infant anthropometric variables were collected. RESULTS Among all women, 80.5% had perineal trauma (60.7% had episiotomy) and 18.5% reported perineal pain. The mean pain intensity score was 4.8 ± 1.9 on the visual analogue scale. Only maternal age (ORa = 1.08) and performance of episiotomy (ORa = 3.80) remained as independent predictors of perineal pain in the final logistic regression model. KEY CONCLUSIONS Perineal pain in the immediate postnatal period was highly associated with older maternal age and use of episiotomy, although the overall reporting of perineal pain was low. IMPLICATIONS FOR PRACTICE Perineal pain following vaginal birth is associated with interventions during labour as well as with maternal characteristics. Despite the negative impact on a womans daily activities, perineal pain following birth is neglected by care givers and usually not reported by women who may consider it to be a normal outcome of giving birth. Care providers need to ensure all interventions during labour and birth are informed by evidence of benefit and that barriers to implementation of evidence are addressed. Further work is needed to obtain the views of women in Brazil on their health and well-being following birth.

Parto domiciliar planejado: resultados maternos e neonatais

The hospitalization of all women in labour, in the interests of thesafety and well-being of mother and baby introduced mechanical,impersonal and interven...

Analysis of pelvic floor musculature function during pregnancy and postpartum: a cohort study

AIM To compare the measurements of womens pelvic floor musculature strength (PFMS) during pregnancy and postpartum period. BACKGROUND Pregnancy and childbirth can have an influence on the muscles and pelvic floor and can cause morbidities of womens genito-urinary tract. DESIGN A prospective cohort study. METHODS There were included 226 primigravidae women, attended by community health services in the city of Itapecerica da Serra, Sao Paulo, Brazil. The participants were followed in four stages: (1) within 12 weeks of pregnancy; (2) between 36-40 weeks of pregnancy; (3) within 48 hours after childbirth; (4) 42-60 days after childbirth. Data were collected from February 2007-August 2008. The pelvic floor musculature strength was evaluated by perineometry and digital vaginal palpation in stages 1, 2 and 4. The final sample included 110 women who completed all four stages of the study. RESULTS The pelvic floor musculature strength of the women did not change significantly during pregnancy or after delivery (anova: p = 0·78). In all three examined stages, a low-intensity pelvic floor musculature strength was prevalent (in mmHg: stage 1 = 15·9; stage 2 = 15·2, stage 4 = 14·7), with scores from 0-3 on the Oxford scale. The pelvic floor musculature strength did not differ in relation to maternal age, skin colour, conjugal status, dyspareunia, stool characteristics, type of delivery, or conditions of the perineum. An interaction between maternal nutritional state and newborns weight may affect the pelvic floor musculature strength (manova: p = 0·04). CONCLUSION Pregnancy and childbirth did not reduce significantly pelvic floor musculature strength. The perineometry and digital vaginal palpation used to assess the pelvic floor musculature strength were well accepted by the women. RELEVANCE TO CLINICAL PRACTICE In clinical practice, digital vaginal palpation is effective for supporting the diagnosis of urinary, intestinal and sexual dysfunctions. Perineometry use is particularly important together with the performance of perineal exercises with biofeedback in the treatment these disorders.

Desafios da formação em enfermagem no Brasil: proposta curricular da EEUSP para o bacharelado em enfermagem

The School of Nursing of the University of Sao Paulo is involved in a process to change the Baccalaureate curriculum, and its implementation is planned to happen in 2009. This is a presentation of the main guidelines of the new curriculum. It is structured in three cycles: Basic (1.500h), Intermediate (1.500) and Final (1.000h), with 4.000h in total, in eight semesters. The aim of the change is to increase de integration among its courses and departments, to promote the autonomy of the student and to adopt as guidelines the principles of the Unified Health Care System in Brazil. The profile aimed is of a general practitioner in nursing, with technical, scientific, ethical and political competencies to provide nursing care to individuals, families and social groups.The School of Nursing of the University of Sao Paulo is involved in a process to change the Baccalaureate curriculum, and its implementation is planned to happen in 2009. This is a presentation of the main guidelines of the new curriculum. It is structured in three cycles: Basic (1.500h), Intermediate (1.500) and Final (1.000h), with 4.000h in total, in eight semesters. The aim of the change is to increase de integration among its courses and departments, to promote the autonomy of the student and to adopt as guidelines the principles of the Unified Health Care System in Brazil. The profile aimed is of a general practitioner in nursing, with technical, scientific, ethical and political competencies to provide nursing care to individuals, families and social groups.

Resultados maternos e neonatais em centro de parto normal peri-hospitalar e hospital

OBJECTIVE: To compare maternal and neonatal outcomes in low-risk women assisited in an alongside birth center and at a hospital. METHODS: A cross-sectional study was conducted with a representative sample of low-risk women in Sao Paulo (Southeastern Brazil), from 2003 to 2006. The study included 991 women who delivered a child at the alongside birth center and 325 who delivered a child at a hospital. Data were obtained from medical records. A comparative analysis was performed for all of the women, who were stratified according to parity. The chi-square test and Fishers exact test were used to compare outcomes between women who delivered in alongside birth center and those who gave birth in the hospital. RESULTS: There was a homogeneous distribution of women according to parity (45.4% were nulliparous, and 54.6% had one or more previous deliveries). Statistically significant differences were found in the frequency of amniotomy (more frequent in nulliparous women treated at the hospital), the use of oxytocin during labor, and the use of postpartum analgesia (both more frequent among women of any parity treated at the hospital). The rate of episiotomy was higher in nulliparous women, both in the alongside birth center and at the hospital. Neonatal interventions were more frequent at the hospital and included aspiration of the upper airways, gastric aspiration, gastric lavage, and the use of an open oxygen mask. Other events that occurred with greater frequency at the hospital included caput succedaneum, respiratory discomfort, and admittance to the neonatal unit. There was no difference in Apgar scores at the fifth minute or cases of maternal or perinatal death. CONCLUSIONS: Care at the alongside birth center involved fewer interventions and had maternal and neonatal outcomes similar to those of the hospital setting.

Randomized controlled clinical trial on two perineal trauma suture techniques in normal delivery

The aim was to compare healing and perineal pain with the use of continuous and interrupted suture techniques in women after normal delivery. A randomized controlled trial was carried out at a hospital birth center in Itapecirica da Serra, Sao Paulo, Brazil. A total of 61 women participated with episiotomy or second degree perineal tear, allocated in two groups according to the continuous (n=31) or interrupted (n=30) suture techniques. The main outcomes evaluated were edema, ecchymosis, hyperemia, secretion, dehiscence, fibrosis, frequency and degree of pain (evaluated by numerical scale from 1 to 10). Data were collected during hospitalization and after discharge (four and 41 days after birth). Healing occurred by first intention in 100% of cases in both suture techniques. There were no statistically significant differences for the occurrence of morbidities, except for perineal pain due to palpation at four days after delivery, which was more frequent among women with interrupted suture.O objetivo foi comparar a cicatrizacao e a dor perineal com a utilizacao das tecnicas de sutura continua e separada em mulheres com parto normal. Realizou-se estudo controlado aleatorio, em centro de parto normal, em Itapecerica da Serra, Sao Paulo. Participaram 61 mulheres com episiotomia ou rotura perineal de segundo grau, alocadas em dois grupos, segundo a tecnica de sutura continua (n=31) ou separada (n=30). Os principais desfechos avaliados foram edema, equimose, hiperemia, secrecao, deiscencia, fibrose, frequencia e magnitude da dor (avaliada pela escala numerica de 1 a 10). Os dados foram coletados na internacao e apos a alta (quatro e 41 dias pos-parto). A cicatrizacao foi por primeira intencao em 100% dos casos, nas duas tecnicas de sutura. Nao houve diferenca estatisticamente significante para a ocorrencia de morbidades, exceto na dor perineal a palpacao, com quatro dias de pos-parto, que foi mais frequente entre as mulheres com sutura separada.El objetivo fue comparar la cicatrizacion y el dolor perineal utilizando tecnicas de sutura continua y separada, en mujeres que realizaron parto normal. El estudio fue controlado aleatorio, realizado en un centro para parto normal en Itapecerica de la Sierra, Sao Paulo. Participaron 61 mujeres con episiotomia o desgarro perineal de segundo grado, distribuidas en dos grupos (sutura continua n=31 y sutura separada n=30). Las principales medidas evaluadas fueron edema, equimosis, hiperemia, secrecion, dehiscencia de herida, fibrosis, frecuencia y magnitud del dolor (evaluada por escala numerica de 1 a 10). Los datos fueron recolectados durante la hospitalizacion y despues del alta (de 4 a 41 dias post-parto). La cicatrizacion fue por primera intencion en 100% de los casos, para las dos tecnicas de sutura. No se encontro diferencia estadisticamente significativa en los casos de morbilidad, con excepcion del dolor perineal a la palpacion al cuarto dia post-parto, el que fue mas frecuente en mujeres con sutura separada.

Use of hyaluronidase to prevent perineal trauma during spontaneous delivery: a pilot study.

Our objective was to compare the frequency, degree, and location of perineal trauma during spontaneous delivery with or without perineal injections of hyaluronidase (HAase). This was a randomized, controlled pilot study, conducted in a midwife-led hospital birth center in São Paulo, Brazil. Primiparous women (N = 139) were randomly assigned to an intervention group (HAase injection, n = 71) or to a control group (no injection, n = 68). Significant differences were noted between the two groups in frequency of perineal trauma (intervention, 39.4%; control, 76.5%), degree of spontaneous laceration (intervention, 0.0%; control, 82.4%), and laceration located in the posterior region of the perineum (intervention, 54.2%; control, 84.3%). When episiotomy and second-degree lacerations were considered together and women with intact perineum were excluded from the analysis, the difference between the groups was no longer significant. With the use of the HAase enzyme, the relative risk was 0.5 for perineal trauma and 0.0 for second-degree lacerations. The present findings suggest that perineal injection of HAase prevented perineal trauma. These findings provide strong rationale for a larger follow-up study.

Formação profissional de obstetrizes e enfermeiras obstétricas: velhos problemas ou novas possibilidades?

Refere-se as transformacoes na formacao profissional de parteiras, obstetrizes e enfermeiras obstetricas no Brasil, desde a criacao dos cursos de parteiras vinculados as escolas medicas, no seculo XIX, ate as mais recentes experiencias, mediante cursos de especializacao em enfermagem obstetrica. Discute os modelos de formacao dos profissionais que existem em outros paises, considerando tanto o ensino independente da obstetricia como a modalidade vinculada aos cursos de enfermagem. Apresenta proposta de um curso de obstetricia para ser oferecido por escolas de enfermagem.